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Referral Checklist

The Difference in End-of-Life Care

Referral Checklist for Medical Professionals
Referrals: (844) 422-4031

Hospice and Palliative Care

  • Service available to your patients across all settings including home, senior living
    facility, hospital and the Hospice Inpatient Center.
  • Inpatient care available for patients who need another level of care to manage pain or
    other symptoms.
  • 24-hour response for assessment, admission and discharge planning for your patients.
  • Interdisciplinary teams consist of physicians, CRNPs, RNs, LPNs, chaplains, social
    workers, hospice aides, therapists and volunteers.
  • Services available regardless of patients’ limited insurance or financial resources.

REFERRAL INFORMATION

  • Person calling in referral
  • Practice/Hospital
  •  Social Worker/Case Manager Name and Number (if applicable)
  • Phone number

PATIENT INFORMATION

  • Patient’s Name
  • Location
  • Phone number
  • Date of birth
  • Diagnosis

REFERRING PHYSICIAN INFORMATION

  • Name of referring physician
  • Medical management – YES NO
  • Verbal certification – YES NO

CAREGIVER INFORMATION

  • Name of primary caregiver
  • Relationship
  • Contact information
  • (Work)
  • (Home)
  • (Cell)