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

From Our Patients & Their Families

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