Credentials for your medical director and every hospice physician
Hospice physicians and the medical director have rules of their own: a license kept current, a medical director who is an MD or DO named in writing, and federal registrations that sit outside the hospice rules. Personnel Ledger keeps them in each physician's file, with the expiration dates watched.
- 45-day free trial at launch
- No credit card to start
- Unlimited staff and users
- No per-person fees, ever
Built from the federal hospice rules, other federal physician rules, CMS surveyor guidance and CMS survey reports. General information, not legal advice. Confirm your specifics with your state and your accreditor.
A license, a named medical director, and a designee
The hospice Conditions of Participation have no separate physician credentialing process. They ask for a license kept current, and they set rules for who the medical director is and how that is put in writing.
| Who | What the file needs | Rule |
|---|---|---|
| Every hospice physician, employed, contracted or volunteer | A doctor of medicine or osteopathy legally authorized to practice by the state. | §418.114(b)(1); 42 CFR §410.20(b) |
| The medical director | An MD or DO who is a hospice employee or is under contract. One medical director for the hospice and all of its locations. | §418.102; CMS guidance at L0664 |
| A contracted medical director | A contract that specifies the physician who takes on the medical director's responsibilities and obligations. | §418.102(a) |
| The physician designee | A written designation of the physician who acts when the medical director is not available. | §418.102; §418.3 |
| A nurse practitioner as attending physician | An RN license and state authorization to practice as an NP. NPs who first enrolled in Medicare on or after January 1, 2001 also need national certification. | 42 CFR §410.75(b) |
CMS surveyor guidance treats a medical director who is unpaid and not under contract as a volunteer. For nurses, social workers and therapists, see hospice license tracking.
Rules from outside the hospice CoPs, and your own policy
DEA registration
For physicians and nurse practitioners who prescribe controlled substances. Practitioner registrations run three years, and some states add a registration of their own.
21 CFR §1301.13Medicare enrollment
A physician who certifies terminal illness must be enrolled in Medicare in an approved status, or validly opted out. It is a condition of payment, not a CoP, so how often you re-check is your policy.
42 CFR §424.507Exclusion checks
Physicians, contracted and volunteer ones included, belong on the monthly exclusion screening OIG recommends for everyone.
OIG Special Advisory Bulletin, 2013Preparedness training
Emergency preparedness training reaches physicians and the medical director, at hire and at least every two years.
42 CFR §418.113(d)(1)Liability insurance
For contracted physicians, a current professional liability certificate. ACHC checks this for direct-care contracts; elsewhere it is your policy.
ACHC HSP1-8ABoard certification
Certification in hospice and palliative medicine is not required by the federal hospice rules or by any other source we checked. Track it if your policy asks for it.
Agency policyHow the monthly check works, and what to keep as proof: OIG exclusion screening.
Small in number, specific in what they find
Physician findings are rarer than aide or background check findings. When they come, they tend to be about what is in writing.
Who is the director?
In 2025, 17 hospice standard surveys cited L0666, including medical director contracts that did not say which physician was the director and which was the designee.
Training that reaches physicians
A 2025 finding cited a medical director and an associate medical director with no emergency preparedness training every two years.
A license is the base
Beyond a license kept current and the medical director rules, the hospice CoPs add no physician credentialing step. Everything else on this page comes from other federal rules or your own policy.
A physician's file kept like everyone else's
One file per physician
Employed, contracted and volunteer physicians each get a file with their license, registrations and checks.
Designations on file
Record the medical director and physician designee designations with their dates, and attach the contract page that names the physician.
Expirations watched
License and DEA expiration dates come due on their own, with an email to the physician before each one lapses.
Scheduled checks
Set the Medicare enrollment re-check to the interval your policy uses, and keep the monthly exclusion check with everyone else's.
Clinical work stays out
Certifications of terminal illness, orders and visit notes are patient records. They stay in your EMR; there is no field for them here.
Hospice physician credentials, answered
Does a hospice medical director have to be an employee?
No. The medical director must be a doctor of medicine or osteopathy who is either a hospice employee or under contract. If under contract, the contract must specify the physician who takes on the medical director's responsibilities (42 CFR §418.102(a)).
Can a hospice have more than one medical director?
No. CMS surveyor guidance at L0664 expects one medical director for the hospice and all of its locations, with a physician designee to act when the medical director is not available.
Is board certification in hospice and palliative medicine required?
Not by the federal hospice rules, or by any other source we checked. If your own policy requires it, add it as its own requirement.
Do we need to check Medicare enrollment for hospice physicians?
For physicians who certify terminal illness, yes. It is a condition of payment for hospice claims that the certifying physician be enrolled in an approved status or validly opted out (42 CFR §424.507). It is not a Condition of Participation, so the re-check interval is your policy.
What if our medical director is a volunteer?
CMS surveyor guidance at L0664 treats a medical director who is unpaid and not under contract as a volunteer. Record that status in the physician's file along with the license and the designation.
Do nurse practitioners need anything beyond an RN license?
An NP serving as a patient's attending physician needs state authorization to practice as a nurse practitioner as well as the RN license. NPs who first enrolled in Medicare on or after January 1, 2001 must also be certified by a recognized national certifying body (42 CFR §410.75(b)).
This page is general information, not legal advice. Physician requirements come from federal regulation, Medicare payment rules, your state's law and your accreditor, and they change. Confirm your specifics with your state medical board and your accreditor.
Keep the medical director's file as current as everyone else's
Personnel Ledger tracks physician licenses, DEA registrations, enrollment checks and designations in one file per physician. Start a free 45-day trial today.