Medicare Evaluation Tool | ALS ALS - MED EVAL TOOLS Diagnosis: ALSPhysician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Documentation Options*OPTION 1: Patient desires no tracheostomy or invasive ventilation AND displays critically impaired ventilatory capacity as evidenced by FVC < 40% and 2 more of the following symptoms and/or signs listed belowOPTION 2: If unable to perform the FVC test, patients must manifest 3 or more of the symptoms listed below to qualify for hospice care.Symptoms*Check all that apply: Dyspena at rest Orthopena Unexplained confusion Paradoxical abdominal motion Use of respiratory musculature Symptoms of sleep disordered breathing Respiratory speech/vocal volume Unexplained headaches Unexplained anxiety Weakened cough Frequent wakening Daytime somnolence/excessive daytime sleepiness 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.*YesNoI 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.