Medicare Evaluation Tool | Cancer CANCER - MED EVAL TOOLS Diagnosis: CancerPhysician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Please confirm terminal dx*Documentation Options*Please check all that apply: Primary dx/site Patient has had treatment and desires no further treatment Metastatic disease/site Patient declines oncology work up for treatment Please respond YES or NO to the statements in this section:I support hospice care for this patient.*YesNoI will be the 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.