Home Health ServicesHome Medical equipmentHospiceCommunity Health and Wellness

How to make a referral: Hospice Services

  1. 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.
  2. If the patient is undecided about hospice or would like to get more information about hospice, we offer a PATIENT INFORMATIONAL VISIT - call 877-356-4514. 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
  3. 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