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APPLICATION FORM
PALLIATIVE CARE Program
Please note that a referral letter should accompany this application.
PLEASE USE BLOCK LETTERS FOR ALL SECTIONS1. MEMBER AND PATIENT INFORMATION
TO BE COMPLETED
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How to fill out palliative care referral and
How to fill out palliative care referral and
01
Obtain necessary information from patient's medical records and healthcare provider.
02
Complete referral form with patient's demographics, medical history, current symptoms, and reason for referral.
03
Submit referral form to the appropriate palliative care team or provider for review and approval.
Who needs palliative care referral and?
01
Patients with serious illnesses such as cancer, heart disease, lung disease, kidney failure, or dementia.
02
Patients experiencing symptoms such as pain, fatigue, nausea, shortness of breath, or difficulty managing medications.
03
Patients who would benefit from a holistic approach to managing their physical, emotional, and spiritual needs.
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What is palliative care referral?
Palliative care referral is the process of initiating the transfer of a patient to a specialized palliative care team to provide comprehensive support focusing on relief from symptoms and stress of serious illness.
Who is required to file palliative care referral?
Typically, healthcare providers such as physicians, nurse practitioners, or physician assistants are required to complete and file the palliative care referral for eligible patients.
How to fill out palliative care referral?
To fill out a palliative care referral, one must gather patient information, including diagnosis, prognosis, and specific needs, and complete the referral form provided by the healthcare institution or palliative care service.
What is the purpose of palliative care referral?
The purpose of palliative care referral is to ensure that patients with serious illnesses receive appropriate support and care focused on improving quality of life, managing symptoms, and providing emotional and spiritual support.
What information must be reported on palliative care referral?
The information that must be reported generally includes the patient's demographics, medical history, details about their illness, current treatments, and specific needs for palliative care.
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