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Medicare Evaluation Tool | Heart Disease

Heart Disease - MED EVAL TOOLS

Diagnosis: Heart Disease
Physician Name*
Phone Number*
Patient Name*
Patient Information
Medicare 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.*
- 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
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
Name
This field is for validation purposes and should be left unchanged.

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Davis, CA 95618

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Yolo Hospice serves Colusa, Sacramento, Solano, Sutter, and Yolo Counties.

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Yolo Hospice

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YoloCares
Services
News & Events
Join Our Team
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Support Us
Contact Us

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