Home Care / For Physicians / Home Care Referral Form Home Care Referral Form Physician Referral Form for Hospice Care Please fill out the form below as completely as possible. For assistance determining if the patient is a good fit for Hospice Care, please review “Determining Eligibility for Hospice Care“. Physician Information Referring Physician*: Contact Person*: Office Phone*: ( ) - Second three digits Last four digits Start of Care Date Requested*: Medical Record #*: How will you be submitting the patient's medical information?*: Fax: (585) 671-4326eRecord/Care ConnectsUploadFill Out Form Below If you selected Upload above: To share files with Home Care Intake, please use the input below to find the file(s) on your system to include with this submission. Please be sure to convert the file(s) to PDF beforehand. Max. File Size: 3MB.: Patient Information Patient Name*: Insurance Type/Number*: Street Address*: City*: State*: Zip Code*: Date of Birth*: Calendar Does the patient live alone?*: YesNo Phone Number*: ( ) - Second three digits Last four digits Emergency Contact Information: Contact Name*: Contact Phone*: ( ) - Second three digits Last four digits Relationship to Patient*: Does the emergency contact need to be present during initial evaluation visit?*: YesNo Care Information Medical/Surgical diagnosis(es) for which home care is being ordered*: Pertinent medical/surgical history*: Allergies*: If there are none, please enter "None". Disciplines/Services referred and orders*: Skilled NursingPhysical TherapyOccupational TherapyOther If you checked "other" above, please select any additional services needed. Other Services Requested: Speech TherapySocial WorkHHAEquipment