Form DOM1165 C Physician Certification / Recertification of Terminal Illness - Mississippi

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.

Q: What is the purpose of form DOM1165 C?
A: The purpose of form DOM1165 C is to certify or recertify a patient's terminal illness in Mississippi.

Q: Who completes form DOM1165 C?
A: The form is completed by a physician.

Q: What information is included in form DOM1165 C?
A: Form DOM1165 C includes information about the patient's terminal illness and the physician's certification or recertification.

Q: Is there a fee for submitting form DOM1165 C?
A: No, there is no fee for submitting form DOM1165 C.

Q: Can form DOM1165 C be submitted electronically?
A: Yes, form DOM1165 C can be submitted electronically.

Q: Are there any specific guidelines for completing form DOM1165 C?
A: Yes, there are specific guidelines provided on the form for completing it accurately.

Q: Is form DOM1165 C only applicable in Mississippi?
A: Yes, form DOM1165 C is specifically for certifying or recertifying terminal illness in Mississippi.

Q: What should I do with form DOM1165 C once it is completed?
A: Once form DOM1165 C is completed, you should submit it to the appropriate authority as instructed on the form or by your physician.

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Form Details:

  • Released on April 1, 2022;
  • 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;

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.

Download Form DOM1165 C Physician Certification / Recertification of Terminal Illness - Mississippi

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  • Form DOM1165 C Physician Certification / Recertification of Terminal Illness - Mississippi, Page 1
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