Medicare Evaluation Tool | HIV HIV - MED EVAL TOOLS Diagnosis: HIVPhysician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Patient with:*CD4 + count < 25 cells/mc/L ORviral load 100,000 copies/ml (2 or more assays at least one month apart)AND*Check all that apply: CNS lymphoma is systemic lymphoma Loss of at least 10% body mass Mycobacterium avium complex unresponsive to treatment Visceral kaposis sarcoma PPS less than or equal to 50% Supporting Data*Check all that apply: Chronic persistent diarrhea for 1 year, regardless of etiology Concomitant, active substance abuse Advanced AIDS dementia complex Advanced liver disease Persistent serum albumin < 2.5gm/dl. Age > 50 Toxoplasmosis Antiretroviral, chemotherapeutic, and prophylactic drug therapy related specifically to HIV disease Congestive heart failure, symptomatic at rest 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.*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.