Medicare Evaluation Tool | Heart Disease Heart Disease - MED EVAL TOOLS Diagnosis: Heart DiseasePhysician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Documentation Options* The patient has been treated for heart disease or vasodilators The patient has a medical reason for refusing these drug e.g. hypertension, renal disease The patient is not a candidate, by medical criteria or personal choice for cardiac surgery AND*Check all that apply: Meets NYHA IV criteria Is unable to carry on any physical activity without discomfort or shortness of breath Has symptoms of heart failure or angina at rest Any physical activity increases discomfort Ejection fraction <20% Supporting Data*Check all that apply: Treatment-resistant symptomatic supraventricular or ventricular arrhythmias History of cardiac arrest or resuscitation History of unexplained syncope Brain embolism of cardiac origin Concomitant HIV disease Other 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.*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.