Get the free hospice referral form

REFERRAL TO ASHANTI HOSPICE BEREAVEMENT SERVICE Please use this form to refer patients or family members who require bereavement support Please Fax To: (06) 356 6631 PO Box 5349, Palmerston North

How to fill out hospice referral form

How to fill out a hospice referral form:

1. Contact the hospice agency: Begin by contacting the hospice agency that you wish to refer a patient to. They will provide you with the necessary referral form and any additional instructions.
2. Gather patient information: Collect all relevant information about the patient, including their full name, date of birth, address, contact information, and insurance details. It is important to provide accurate and up-to-date information for efficient processing.
3. Complete patient medical history: Fill out the section of the referral form that requires the patient's medical history. Include details about the patient's diagnosis, current medications, allergies, any existing advanced directives, and recent medical treatments.
4. Include primary care physician details: Provide the name and contact information of the patient's primary care physician. This information is essential for coordinating the patient's care with the hospice team.
5. Specify the reason for referral: Indicate the reason for the hospice referral clearly and concisely. Provide a brief description of the patient's medical condition and the need for specialized end-of-life care.
6. Include supporting documentation: If available, attach any relevant medical records, test results, or physician notes that may support the need for hospice care. These documents can offer valuable insights into the patient's medical condition.
7. Obtain necessary signatures: Ensure that the referral form is signed by the referring healthcare provider and the patient or their authorized representative. This verifies the accuracy of the information provided and authorizes the referral to the hospice agency.

Who needs a hospice referral form?

1. Patients with a terminal illness: A hospice referral form is typically required for patients with a terminal illness or a life expectancy of six months or less. These individuals can benefit from the specialized care and support offered by hospice agencies.
2. Healthcare professionals: Referring healthcare professionals, such as physicians, nurses, or social workers, need to complete the referral form to initiate the process of transferring the patient to the hospice care setting.
3. Caregivers or family members: In some cases, family members or caregivers may also need to complete a hospice referral form if they are authorized to make medical decisions on behalf of the patient. They should ensure that all necessary information is provided accurately.

By following these steps, healthcare professionals and authorized individuals can effectively and efficiently fill out a hospice referral form and initiate the process of providing compassionate end-of-life care to patients in need.

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What is hospice referral form?

The hospice referral form is a document used to refer a patient to hospice care services.

Who is required to file hospice referral form?

Healthcare providers, physicians, or medical professionals are required to file the hospice referral form for their patients who meet the criteria for hospice care.

How to fill out hospice referral form?

The hospice referral form can be filled out by providing the patient's medical history, current medical condition, and the reason for the referral to hospice care.

What is the purpose of hospice referral form?

The purpose of the hospice referral form is to initiate the process of admitting a patient to hospice care and ensuring they receive appropriate end-of-life care.

What information must be reported on hospice referral form?

The hospice referral form must include the patient's name, date of birth, medical history, current medical condition, and any relevant medical documents.