Medicare Evaluation Tool | Liver Disease Liver Disease - MED EVAL TOOLS Diagnosis: Liver DiseasePhysician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Patient with:* The patient has Prothrombin time prolonged more than 5 sec. over control, or INR > 1.5 and Serum Albumin < 2.5 gm/dl. AND at least one of the following:*Check all that apply: Ascites, refractory to treatment or patient non-compliant Spontaneous bacterial peritonitis Hepatic encephalopathy, refractory to treatment or patient non-compliant Recurrent variceal bleeding, despite intensive therapy Supporting Data*Check all that apply: Progressive malnutrition Muscle wasting with reduced strength and endurance HBsAg (Hepatitis B) positivity Hepatitis C refractory to interferon Hepatocellular carcinoma Continued alcoholism (>80 gm ethanol/day) Bilirubin, albumin, other liver enzyme levels abnormal 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.