Evercare Hospice Palliative Care Referral Form free printable template

This document is a referral form for submitting patient information to Evercare Hospice & Palliative Care, intended to facilitate the intake process for hospice services.

How to fill out hospice referral form

How to fill out Evercare Hospice & Palliative Care Referral Form

1. Obtain the Evercare Hospice & Palliative Care Referral Form from the official website or healthcare provider.
2. Fill in patient information such as name, date of birth, and contact details.
3. Provide relevant medical history, including diagnoses and prognosis.
4. Include details about current medications and any allergies the patient may have.
5. Specify the primary reason for referral and any specific needs or concerns.
6. List the referring physician's information and contact details.
7. Submit the completed form to Evercare Hospice & Palliative Care through the designated method (fax, email, or mail).

Who needs Evercare Hospice & Palliative Care Referral Form?

1. Patients with a terminal illness seeking end-of-life care.
2. Individuals requiring support for managing chronic pain and symptoms.
3. Families looking for assistance with hospice services.
4. Healthcare professionals coordinating care for patients in need of palliative services.

People Also Ask about

Who can refer for hospice care?

Hospice care starts when disease in a person worsens to the point where any form of treatment can no longer cure or control it. Once a certified physician has determined that an individual's life expectancy may be six months or less if the illness runs its usual course, they are immediately eligible for hospice care.

What hospice doesn t tell you?

What Does Hospice Care Not Include? Hospice care does not include curative treatment. The goal of hospice care is to provide comfort and support rather than to cure the disease. Hospice may not include medications you have grown accustomed to taking, such as chemotherapy or other medical supplements.

What are the four stages of hospice?

Every Medicare-certified hospice provider must provide these four levels of care: Hospice Care at Home. Continuous Hospice Care. Inpatient Hospice Care. Respite Care.

When a referral is received by a hospice which of the following should occur first?

What is the process of hospice referral? First, the client must see their primary care physician. The physician will provide them with information about hospice. The physician will also run some tests to determine things about the individual's health.

What happens when you are referred to hospice?

Hospice is for people who are near the end of their life. It provides medical treatment to relieve symptoms. The goal is to keep you comfortable, not to try to cure your disease. Hospice care also offers emotional help and spiritual support.

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What is Evercare Hospice & Palliative Care Referral Form?

The Evercare Hospice & Palliative Care Referral Form is a document used to initiate the process of admitting a patient into hospice or palliative care services provided by Evercare.

Who is required to file Evercare Hospice & Palliative Care Referral Form?

The referral form must be filed by healthcare professionals such as doctors, nurse practitioners, or social workers who are involved in the patient's care.

How to fill out Evercare Hospice & Palliative Care Referral Form?

To fill out the referral form, the healthcare provider should provide detailed patient information, medical history, and specific hospice or palliative care needs on the form.

What is the purpose of Evercare Hospice & Palliative Care Referral Form?

The purpose of the referral form is to streamline the referral process for patients who require hospice or palliative care, ensuring that all necessary information is collected to facilitate proper care.

What information must be reported on Evercare Hospice & Palliative Care Referral Form?

The form must report patient demographics, medical history, current medical conditions, prognosis, and any specific preferences or needs regarding care.