Hospice Referral Form

Determining Eligibility for Hospice Care

Hospice is a comprehensive service available to patients and their families who have a life expectancy of six months or less.

Medicare A, Medicaid and most insurances have hospice benefits.

Guidelines are based on Local Coverage Determination (LCD) for Hospice eligibility used by National Government Services (NGS), a Medicare fiscal intermediary.

Sometimes a patient does not “fit” into the guidelines but still has a life expectancy of six months or less and therefore is eligible for hospice.

Predicting a life-expectancy of six months or less usually involves a significant, documented deterioration in physical status/function, such as weight loss or decreased function and/or an end-stage disease.

Decline may also be due to refusal of treatments, medications or hospitalization aimed at improving or stabilizing an advanced disease.

A patient can be appropriate for hospice even without a specific end-stage disease.

If your patient does better than initially expected, he or she may get discharged from hospice, yet can always get hospice service at a later time when more appropriate. There is no penalty for early referral.

Please call us if yo think your patient may benefit from hospice service. We would be happy to evaluate your patient for hospice eligibility. Hospice medical director consultation services are also available.

Determining Eligibility for Hospice Care

Physician Referral Form for Hospice Care

Physician Information

Patient Information

Care Information

Health Care Proxy Information