24 Hour Helpline: 1-866-95-CARE-4

Patient Referral

Admission to Hospice

Often, admission into our Hospice care begins with a call from a spouse or an adult child inquiring whether our services may be the right solution for their loved one.

A referral to Care One Hospice can come from anyone – a family member, a friend, a physician or the patient. To be admitted into our Hospice care, patients must have a physician’s order.

To make a referral into our care, please complete the referral form below. If you require additional information, please contact us at 866-952-2734 or by email at web@careonehospice.com

Referral Source

* Referrer's Name

Contact Name, if not Referrer

* Phone Number

* Contact's Email

* Relationship to Patient

Patient Information

* Patient's Name

* Patient's Phone Number

Street

City

State

Zip Code

Physician Information

Referring Physician

Primary Diagnosis

Comments

 

Fields denoted with asterisk (*) are required.