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 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 clinically with patient (Doctor visit notes, RN notes)
Current Medication List
Physician order for hospice
DNR/DNH (if available)
If you have any questions, please call the Intake Department at (207) 289-3640.