How to make a referral: Hospice Services
- Verify that the person has a terminal illness / end stage disease, is no longer seeking curative treatment and the physician would not be surprised if the patient died within 6 months.
- If the patient is undecided about hospice or would like to get more information about
hospice, we offer a FREE PATIENT INFORMATION VISIT. Call
608-241-6900 or 800-900-8040
and ask for the admissions department. Please have the following information available
before you call:
- Patient's name and DOB
- Patient's address and phone number
- If in a facility, name of facility, facility contact name and phone number
- If activated HCPOA, name of POA and phone number
- Ordering/Attending Physician
- Admitting diagnosis
- Once the patient has decided to be placed on hospice services, the following
information is needed by our admissions dept prior to admission. Please fax
to 866-553-0869 or 608-241-8381:
- A copy HCPOA form, name of POA and phone # to coordinate admission.
- Insurance information (including numbers)
- Initial signed physician orders*
- Current medication list
- History & physical/medical summary statement (if available)*
- Allergy information
- Physician Certification of Terminal Illness form (see attached)*
- Comfort Care MD Physician Order form (see attached)*
*Admission dept can get these items directly from the MD
Per Medicare Regulations, the Physician Certification of Terminal Illness form MUST be completed and returned prior to admission. We cannot admit without the form!
Our Hospice Liaison is available as your resource for more information or to answer any hospice questions.
Please call her directly at the phone number below or ask our Central Intake Staff to have her call you.
Karri Kelliher, Hospice Liaison
Direct cell phone: 608-225-4171
Admission Department: 800-900-8040