Physician Medical Authorization Form

Medical Authorization Form

This form is to be completed by a Treating Physician, Physician's Assistant, Nurse Practitioner or Registered Nurse ONLY.
As a reminder, the patient application will remain pending until we receive this signed Medical Authorization and supporting documentation.
Patient's Name*

First NameLast Name
Patient's Terminal Diagnosis*
Date of Diagnosis*

MonthDayYear
Date
Current Life Expectancy in Months*
Physician's Name*

First NameLast Name
Physician's Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Physician's Phone Number*

Area CodePhone Number
Name of Treatment Facility or Hospital*
Name of Social Worker/Child Life Specialist*

First NameLast Name
Social Worker/Child Life Specialist Phone Number*

Area CodePhone Number
Social Worker/Child Life Specialist Email*
example@example.com
Has the patient been advised about hospice options?*

YesNo
Has the patient declined hospice services?*

YesNo
Please provide details.*
Please upload Physician Letter*

Browse Files
Letter, on official letterhead, stating patient is under your care with treating physician's signature. Cancelof
I certify that I am a medical professional treating the patient and acknowledge to the best of my ability that my patient has a life expectancy of six months or less. I conﬁrm that all information provided above is accurate. I have discussed Project 4031’s service capabilities with my patient and have deemed the request to be reasonable. I recognize that dependent on the request, there are potential risks involved. I have discussed these possible risks and informed my patient that they will assume the full liability of all injuries, damages, or loss, regardless of severity that they may sustain as a result of said participation. To the best of my knowledge I believe my patient is an eligible candidate for assistance and I believe it will improve their quality of life. I agree to provide documentation on official letterhead stating that this individual is in fact a patient under my care.
Signature of Physician/PA/NP/RN only*

Clear
Title of Signer*
Date of Signing*
Should be Empty: