How to make a referral: Hospice Services
Verify the Individual:
- Has a terminal illness/end stage disease
- Is no longer seeking curative treatment
- Physician would not be surprised if death occurred within six months
If the individual is undecided about hospice services we offer Informational Visits. To set-up a visit call 608-241-6900 or 800-900-8040. Please have the following information available before you call.
- Name and DOB
- Address and phone number
- If residing in a facility, the facility contact and phone number
- If activated HCPOA, POA name and phone number
- Ordering/attending physician
- Admitting diagnosis
Once the patient had decided to receive hospice services, the following information is needed prior to admission. Please fax the following information to 608-241-8381 or 866-553-0869.
- Copy of HCPOA form, POA name and phone number
- Insurance information (including numbers)
- Initial signed physician orders*
- Current medication list
- History and physical/medical summary statement (if available)*
- Allergy information
- Physician Certification of Terminal Illness/Comfort Care Form
*Admissions department can get these forms directly from the physician
Per Medicare regulations, the Physician Certification of Terminal Illness MUST be completed prior to admission. We cannot admit without the form.