Medicare Evaluation Tool | Renal Disease

Diagnosis: Renal Disease
Physician Name*
Phone Number*
Patient Name*
Patient Information
Medicare requires documentation of need for hospice through prognostic data. Please supply that below:
Please confirm terminal dx:*
Patient or patient’s legal designee desires:*
Check all that apply:
- No dialysis
- Discontinuing dialysis
- No transplant
Comorbid conditions of a severity to warrant medical treatment (within the last year):*
Check all that apply:
- Patient with creatinine clearance of < 10cc/min (less than 15cc/min for diabetics) or < 15cc/min (<20cc/min for diabetics) with comorbidity of CHFPyelonephritis or other UTI
- Serum creatinine > 8.0mg/dl (> 6.0mg/dl for diabetics) Decubitus ulcers
- Decubitus ulcers
- Estimated glomerular filtration rate (GFR) <10 ml/min
Supporting Data, Comorbid Conditions:*
Check all that apply:
- Mechanical ventilation
- Chronic lung disease
- Advanced liver disease
- Platelet count <25,000
- Gastrointestinal bleeding
- Malignancy (other organ system)
- Advance cardiac disease
- Immunosupression or AIDS
- DIC
- 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.*
- Yes
- No
I will be patient’s attending physician*
- Yes
- No
I have discussed hospice with patient/loved ones.*
- Yes
- No
I have discussed terminal diagnosis when it becomes necessary.*
- Yes
- No
- Third Choice
I will sign death certificate when it becomes necessary.*
- Yes
- No
- 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

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Diagnosis: Renal Disease

Patient Information

Please respond YES or NO to the statements in this section:

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