How to Refer a Patient

To refer one of your patients to Hospice of Southern Maine, please fax the following form to our Access 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 Access Department at (207) 289-3649.

Download Referral Form

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 Access Department at 289-3649.

From Our Volunteers

“With each assignment I learn so much from the patient and/or family.  I may learn about the need for patience or how much humor can make such a difference, and how important is it not to judge.”  —Virginia Ballard”

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