Physician Referral Form

Hospice Care

Palliative Medicine
Hospital
Long Term Care Community
Palliative Medicine Clinic

Pediatric Care- Kids Path^®
Hospice Care

Assessment Needed

First name of patient being referred to HPCCR *

Last name of patient being referred to HPCCR *

Patient's date of birth

Your first name *

Your last name *

Your phone number *

What is your relationship to the person/patient being referred for HPCCR care? *

Name of Hospital/doctor's office/long term care community submitting referral

Office Name

Phone Number

Facility Name

Phone Number

Insurance Provider Name

Phone Number

Consulting Physician First Name

Consulting Physician Last Name

Consulting Physician Telephone

Following/Attending Physician First Name

Following/Attending Physician Last Name

Following/Attending Physician Telephone

Case Manager's First Name

Case Manager's Last Name

Case Manager's Phone Number

What is the current location of the patient being referred for HPCCR care?

Additional Diagnoses

What are the primary reasons you are requesting hospice or palliative care for this patient? (check all that apply)

Pain and/or symptom management
Help with medication management
Help in understanding the illness

Assistance with self-care (bathing, dressing, eating)
Support for family
Making decisions about care options

Help with coping emotionally
End-of-life care
Other

How did you hear about Hospice & Palliative Care Charlotte Region? (check all that apply)

Word of mouth
HPCCR advertisement in a publication
Patient's healthcare provider

Search engine (Yahoo, Google, etc.)
HPCCR website
HPCCR fundraising event

Know a HPCCR employee
Have used HPCCR services in the past
Other (please specify)

All information provided through this form to HPCCR is secure and will be treated as such. Information gathered will not be shared and will be kept strictly confidential.

Physician Referral Form

If you would like immediate assistance, please call us at 704.375.0100