Special Executive Financial Security

6. Licensed Health Care Practitioner’s Statement of Chronic Illness (continued) 4. Is the patient unable to perform without substantial assistance one or more of the Activities of Daily Living (ADLs) listed below due to a loss of functional capacity? (Substantial assistance means hands-on or standby assistance from another person without which an individual receiving such assistance would be unable to perform the ADL.) o Yes o No If Yes, indicate the approximate date the patient was first unable to perform the particular ADL and continue to Question 5. If No, continue to Question 8.

Date First Unable to Perform

Activity of Daily Living

Bathing – Washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower.

/

/

SAMPLE Continence – The ability to maintain control of bowel or bladder function, or, when unable to maintain control, the ability to perform associated personal hygiene, including caring for a catheter or colostomy bag. / / Dressing – Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs. / / Eating – Feeding oneself by getting food into the body from a receptacle, such as a plate, cup, or table by a feeding tube or intravenously. Eating does not include preparing a meal. / / Toileting – Getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene. / / Transferring – Moving into or out of a bed, chair, or wheelchair. Transferring does not include the task of getting into and out of the tub or shower. / / 5. Is it likely the patient will require hands-on or standby assistance from another person in performing 2 or more ADLs for the remainder of his or her lifetime? o Yes o No If Yes, circle those ADLs and continue to Question 7: Bathing Continence Dressing Eating Toileting Transferring If No, continue to Question 6. 6. Is it likely the patient will require hands-on or standby assistance from another person in performing 2 or more ADLs for the next 90 days? o Yes o No If Yes, circle those ADLs: Bathing Continence Dressing Eating Toileting Transferring If No, continue to Question 8. 7. Please provide results of any physical examination findings and diagnostic studies that support the patient’s ADL dependencies identified above. 8. If the patient has had a significant decline in cognitive ability, please address the following questions (a, b, c) based on the following definition of severe cognitive impairment and established using clinical evidence and standard tests. Severe Cognitive Impairment – a loss or deterioration in intellectual capacity that is (a) comparable to (and includes) Alzheimer’s disease and similar forms of irreversible dementia, and (b) measured by clinical evidence and standardized tests that reliably measure impairment in the individual’s (i) short-term or long-term memory, (ii) orientation as to people, places, or time, and (iii) deductive or abstract reasoning. a) Describe your patient’s level of cognitive impairment based on clinical assessment and standardized screening tools.

Standardized Screening Tool

Date of Evaluation / / / /

b) Does the patient require continuous supervision for protection from threats to health and safety due to severe cognitive impairment? If Yes, is it likely that the patient will require continuous supervision to protect himself or herself or others due to a severe cognitive impairment for the remainder of his or her lifetime? If No, is it likely the patient will require continuous supervision to protect himself or herself or others due to a severe cognitive impairment for the next 90 days? c) Has your patient’s driver’s license been revoked? If Yes, approximate date / /

o Yes o No

o Yes o No

o Yes o No o Yes o No

(continued)

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COMB 115174-2

Ed. 10/2017