How to Refer a Patient
To refer one of your patients to Hospice of Southern Maine, please fax the following form to our Intake Department at (207) 289-3685 or give it to the hospice nurse who sees patients at your facility. If you have any questions, please call the Intake Department at (207) 289-3640.
Following is a checklist of paperwork required to complete the referral process:
- Demographic sheet (include name, address, insurance information, SS#, etc.)
NOTE: A complete SS# is required for insurance verification purposes
- History and Physical or discharge summary from a recent hospital stay. If no H & P available include clinical notes to help give a picture of what is happening clinically with patient (Dr. visit notes, RN notes etc.)
- Current Medication List
- Physician order for Hospice
- DNR / DNH (if you have an order)
If you have any questions, please call the Intake Department at 289-3640.