Adding Life to Days

Serving Colusa, Sacramento, Solano, Sutter and Yolo Counties.

Make a Referral

Give

About Us
Healthcare Providers
Citizens Who Care
YoloCares
Services
News & Events
- News
- Events
- Videos
- Hospice Stories
- Blog
- ACP Workshops
Join Our Team
Recursos en Español
Support Us
Contact Us

You are here: Home / For Healthcare Providers / Yolo Hospice’s Medicare Evaluation Tools / Medicare Evaluation Tool | HIV

Medicare Evaluation Tool | HIV

HIV - MED EVAL TOOLS

Diagnosis: HIV
Physician Name*
Phone Number*
Patient Name*
Patient Information
Medicare requires documentation of need for hospice through prognostic data. Please supply that below:
Patient with:*
- CD4 + count < 25 cells/mc/L OR
- viral 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.*
- 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
Comments
This field is for validation purposes and should be left unchanged.

Share this:

Tweet

Like this:

Like Loading...

Latest News

Haven’t We Been Here Before? August 18, 2020
2020 Five Wishes Workshop July 23, 2020
Five Wishes – Week 5 Q & A July 22, 2020
Five Wishes – Week 4 Q & A July 14, 2020
Five Wishes – Week 3 Q & A July 8, 2020

For Healthcare Providers

Make a Referral
Patient Evaluation Service
Who Is Eligible for Hospice?
Yolo Hospice’s Medicare Evaluation Tools

Contact Us

Yolo Hospice

1909 Galileo Court, Suite A
Davis, CA 95618

(530) 758-5566 or (800) 491-7711

Connect

Facebook
Twitter
Email

Service Area

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

View cities and our Service Area Map

Pages

About Us
Healthcare Providers
Services
News & Events
Join Our Team
Blog
Support Us
Contact Us

Copyright © 2020 · Yolo Hospice Theme on Genesis Framework · WordPress · Log in

Yolo Hospice

About Us
Healthcare Providers
Citizens Who Care
YoloCares
Services
News & Events
Join Our Team
Recursos en Español
Support Us
Contact Us

%d bloggers like this: