Fax_Medical_Certification_Worksheet_Cover_Sheet



F A X[Company Name][Street Address][City, ST ZIP Code][phone][website]To: [Recipient Name]Fax number: [fax]From: [Your Name]Fax number: [fax]Date: [Click to select date]Regarding: Medical Certification Worksheet[Subject]Phone number for follow-up:[phone]URGENT REPLY REQUESTEDComplete the attached Medical Certification Worksheet. Do not leave any items blank, including items 27 through 38.Did you enter the chain of events that directly caused the death? Remember to enter the approximate interval: onset to death for each condition listed. Are the entries legible?Please sign and date the form and be sure to include your name, address and license number typed or handwritten legibly. All information from this worksheet will be entered into the electronic system.Is the certifier a physician, CRNP, or PA-C? Remember, RN’s cannot certify a death in PA.Double check your entries. If information is incomplete, missing or incorrect, the form will be returned to you for resubmission and will cause delays for the family in terms of obtaining certified copies of the death record.Return the completed worksheet to the funeral director at the fax number or email address listed above ASAP. Note that according to the Vital Statistics Law of 1953, death records must be filed within 96 business hours of the death. ................
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