Request for Hospice Services Referring Physician or Family Member Name Facility/Address Phone Fax Email Requested Start of Care Date (on or before) PATIENT INFORMATION Name Date of Birth Gender MaleFemale Address Phone Family Contact/Relationship Phone Medical Information/Reason for Referral **For Physician Use Only** PHYSICIAN ORDER FOR HOSPICE SERVICES Diagnosis: I certify that this patient has a terminal diagnosis with a prognosis of 6 months or less if the disease runs its normal course. Diagnosis SelectCancerAlzheimer's DiseaseCHFCOPDDementiaEnd State Liver DiseaseIHDParkinson'sMuscular DystrophyRenal FailureOther (please explain below) Other: Areas of Volunteer Interest (select all that apply) Evaluate and Admit to Hospice Services if AppropriateEducation Meeting with patient and familyLicensed/ProfessionalI will follow my patient as attending while they are on Hospice CarePatient is a DNR Orders (Medication/DME/Diet/Other Orders) Insurance Information SelectMedicareMedi-CalPrivate (HMO/PPO) ID# Group (if applicable) Form Completed By/Date By checking this box I hereby attest that all the information provided here is true and accurate to the best of my knowledge. Telephone: (310) 264-8413 Fax: (310) 829-6032 THANK YOU FOR YOUR REFERRAL!