Referral From a Long-term Care Facility
To refer one of your patients to Hospice of Southern Maine, please fax the following information to our Intake Department at (207) 289-3685 or give it to the hospice nurse who sees patients at your facility.
- Patient Name
- Family contact person & phone number
- Facility contact person & phone number
- Patient demographic sheet (including name, address, insurance info, etc.)
- History and physical or discharge summary from a recent hospital stay OR
- clinical notes to help give a picture of what is happening medically with patient (Doctor visit notes, RN notes)
- Current medication list
- Physician order for hospice
- DNR/DNH (if applicable)
If you have any questions, please call the Intake Department at (207) 289-3640 or at (866) 621-7600.
For your convenience, our fax number is: (207) 883-1040
