Physician Page

Referral Order Cover Sheet

Fax To: 251-287-8948 Attention: Admissions

Date:

Home Hospice Eval and Treat

Hospice InPatient Unit Eval and Treat

Patient Name:

Phone:

Date of Birth:

SS#

Diagnosis:

Patient Address

Insurance Information:

Emergency Contact Name:

Emergency Contact Phone:

Physician Signature:

Physician Printed Name:

Patient Progress Note: (or attach last visit note)

13 + 6 =

Most insurance covers 100% for hospice service.
Visitors are allowed 24/7 with no limit to number of visitors or age
All IV antibiotics, dialysis, cancer treatments, fluids and tube feeds are stopped in the Inpatient unit and the focus changes from cure to comfort.
We can accommodate palliative extubations (removal of ventilator) at the Retreat to provide a peaceful environment for the family.
After a period of time, if the patient fails to decline, we will help to assist the patient in returning home or to a nursing home.

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