Medicare Evaluation Tool | Renal Disease Diagnosis: Renal DiseasePhysician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Please confirm terminal dx:*Patient or patient’s legal designee desires:*Check all that apply: No dialysis Discontinuing dialysis No transplant Comorbid conditions of a severity to warrant medical treatment (within the last year):*Check all that apply: Patient with creatinine clearance of < 10cc/min (less than 15cc/min for diabetics) or < 15cc/min (<20cc/min for diabetics) with comorbidity of CHFPyelonephritis or other UTI Serum creatinine > 8.0mg/dl (> 6.0mg/dl for diabetics) Decubitus ulcers Decubitus ulcers Estimated glomerular filtration rate (GFR) <10 ml/min Supporting Data, Comorbid Conditions:*Check all that apply: Mechanical ventilation Chronic lung disease Advanced liver disease Platelet count <25,000 Gastrointestinal bleeding Malignancy (other organ system) Advance cardiac disease Immunosupression or AIDS DIC None of the above Other*Please specify:Please respond YES or NO to the statements in this section:I support hospice care for this patient.*YesNoI will be patient’s attending physician*YesNoI have discussed hospice with patient/loved ones.*YesNoI have discussed terminal diagnosis when it becomes necessary.*YesNoThird ChoiceI will sign death certificate when it becomes necessary.*YesNo Based on the information indicated above, the above named patient has a medical prognosis that life expectancy is six (6) months or less, if the terminal illness runs its normal course. Digital Signature*Please enter your name below to serve as your electronic signature.Verification This iframe contains the logic required to handle Ajax powered Gravity Forms.