Home Care / For Physicians / Hospice Referral Form Hospice Referral Form Physician Information Referring Physician*: Contact Person*: Office Phone*: ( ) - Second three digits Last four digits Start of Care Date Requested*: CalendarNow 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 Does another person need to be present during initial evaluation visit?*: YesNo If "yes", Contact Name: If "yes", Contact Phone: ( ) - Second three digits Last four digits Care Information Select a Hospice*: Ontario-Yates County Monroe County Terminal diagnosis(es) for which hospice is being ordered*: Pertinent medical/surgical history that clarifies appropriateness for hospice*: Allergies*: Pertinent social history*: Prognosis*: 3 months6 monthsOther If "other", please indicate length of time: Other Services Requested: EquipmentSignature Care ServicesMeals on Wheels Advance Directives DNR: YesNo MOLST: YesNo Health Care Proxy Information Is the Proxy completed?*: YesNo If "no," Please Explain: If "yes" please provide the Proxy's Information below: Proxy Name: Proxy Relationship: Proxy Phone: ( ) - Second three digits Last four digits