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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.

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

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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

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

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