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This version of the form is not currently in use and is provided for reference only. Download this version of
Form DOM1165 C
for the current year.
Form DOM1165 C Physician Certification / Recertification of Terminal Illness - Mississippi
What Is Form DOM1165 C?
This is a legal form that was released by the Mississippi Division of Medicaid - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is form DOM1165 C?
A: Form DOM1165 C is the Physician Certification/Recertification of Terminal Illness form used in Mississippi.
Q: What is the purpose of form DOM1165 C?
A: The purpose of form DOM1165 C is to certify or recertify that a patient has a terminal illness and is eligible for hospice care.
Q: Who uses form DOM1165 C?
A: Form DOM1165 C is used by physicians in Mississippi who are certifying or recertifying a patient for hospice care.
Q: What information is required on form DOM1165 C?
A: Form DOM1165 C requires information about the patient's diagnosis, prognosis, and need for hospice care, as well as the physician's certification or recertification statement.
Form Details:
- Released on April 1, 2018;
- The latest edition provided by the Mississippi Division of Medicaid;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form DOM1165 C by clicking the link below or browse more documents and templates provided by the Mississippi Division of Medicaid.
