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Referral Page

PLEASE ATTACH THE FOLLOWING DOCUMENTS WITH THIS REFERRAL:

Primary Point of Contact and phone number for scheduling

Patient demographic sheet

Copy of insurance card (if available)

History & Physical

Diagnostic reports (CT, MRI, PET scan, lab tests, biopsy, x-ray, etc)

Recent hospital records (if available)

Physician progress notes

Height/Weight

 FAX to 502-496-0152

• Patient's First Name
• Patient's Last Name
• Address
• DOB
• SSN
• Contact Phone
• Contact Email
• Patient Representative & Relationship (if applicable)
• Primary Health Insurance: Medicare, Medi-Cal, other
• Medicare Policy #
• Medi-Cal Policy #
• Group
• Ordering Physician (Printed Name)
• Alternative Contact/Office Contact (Printed Name)
• Contact Phone
• FAX
• Terminal Diagnosis
• Secondary Diagnosis
• Other
• I certify that this patient is under my care and to the best of my medical knowledge, given the data available, that this patient is terminally ill with the expectancy of six months or less if the terminal illness runs its normal course. Type full name.
• Please note yes or no for the following two questions.
• I wish to follow the patient and be contacted directly for all orders and changes in condition. Should the need arise for a change in the current plan of care the Hospice Physician can be designated in my absence. I wish to sign the Death Certificate.
• I do not wish to follow patient and/or sign the death certificate. Please assign hospice medical director to follow.