Contact Us – Hospice Referral Form

Let us know how VitalCaring can help you or a loved one. Call 1.844.337.6813 or fill out the form below and we’ll be in touch soon. We kindly request that you refrain from including any patient details in this form.

VitalCaring Hospice Referral Form

Patient Information

Name(Required)

First Last

MI:

SSN:(Required)

DOB:(Required)

Address:(Required)

City/State:(Required)

Zip:(Required)

Phone:(Required)

Emergency Contact:(Required)

Phone:(Required)

Insurance

Insurance:(Required)

Policy #:(Required)

Group #:(Required)

Phone:(Required)

Address:(Required)

*MAY ATTATCH COPY OF MOST RECENT DEMOGRAPHICS SHEET

Referral Checklist

Most Recent Office Notes, Supporting Documentation for Terminal Diagnosis

Most Recent Labs/Imaging/Diagnostic Reports

Most Recent Hospitalization Records, Including D/C Summary

Demographics Sheet

Signed Hospice Order (May be this sheet or on provider order)

Any Specialist Records to Support Terminal Diagnosis

Medication List

Hospice Referral

Ordering MD

Phone #:

Fax #:

PCP (if different than ordering MD):

Diagnosis:

Evaluate and Admit to Hospice if Appropriate

Ordering Physician Signature:

Date(Required)

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Employees
To contact our Human Resources team, please call 844.654.1274.
Patients and Providers
If you are a patient or provider and need assistance, please call 1.844.337.6813.