You may use this tool to evaluate a person who you feel is terminally ill (i.e., the person's life expectancy is six months or less if the disease follows its normal course) for eligibility for enrollment in a Hospice program. This tool will collect certain data about the patient's terminal illness(es) to compare against the Medicare Hospice eligibility criteria.

The information will be asked for in sections, as indicated in the table below. At the end of each section, after you have entered the information or made your selection(s) from the list that is presented, be sure to click on the "Save" button to save your work! There is no Individually Identifiable Health Information (Protected Health Information, or PHI) collected during this screening process. After you have entered your data, you will be able to generate a summary report.

The following tasks are designed to be done sequentially. Click where indicated when you are ready to perform the task.

Task
Enter demographics and select potentially certifiable diseases	Click here
Enter patient data for the selected diseases	Click here
Generate Report	Click here