Referrals

Referrals

Referral Form

The form below can be used to refer a patient to our hospice services. Once completed in full please fax the form to us. It is essential to fill all the fields. Process of this referral will be delayed if there is insufficient supporting evidence. Please fax referrals to: (916) 725-2511

Download form here - First Call Hospice Referral Form


A person may qualify for hospice due to heart disease if you see:

  • Shortness of breath when the person is at rest or lying down
  • Frequent visits to the emergency room
  • Swelling in hands, arms, legs or feet
  • Dizziness, increased weakness or chest pain when resting

A person may qualify for hospice because of pulmonary (lung) disease if you see:

  • Shortness of breath when the person is at rest or lying down
  • They person is on oxygen constantly
  • The person has infections that won’t heal
  • Medications to treat lung disease don’t always ease symptoms or provide relief
  • There are frequent visits to the emergency room

A person may qualify for hospice because of renal (kidney) disease if you see:

  • The person is a candidate for dialysis but prefers not to undergo treatment
  • The person has other significant health conditions such as heart, liver or lung disease
  • The person is experiencing confusion, rash and itching, nausea and vomiting or restlessness

A person may qualify for hospice because of a stroke, come or ALS (amyotrophic lateral sclerosis), if within the last six months you’ve seen:

  • The person cannot walk or sit up without help, the person cannot eat, dress or bathe without assistance and the person has incontinence of bowel and bladder
  • He or she has had pneumonia, urinary tract infections or other repeated infections, skin breakdown (ulcers) that won’t heal or recurrent fever after antibiotics
  • The person has trouble swallowing and is eating and drinking less – may have been discussion about artificial feeding (peg tube)

A person may qualify for hospice because of liver disease if you see:

  • The person is not a candidate for transplant
  • The person has consistent large or increased amount of fluid in stomach area (ascites)
  • The person is less aware of surroundings and environment
  • There is change in mental status, sleep disturbance or sleeplessness, depression, slurred speech, mood swings or tremors

A person may qualify for hospice because of cancer if you see:

  • Disease with metastases at presentation
  • Progression from an earlier stage of disease to metastatic disease with decline in spite of continued disease-related therapy (chemo or radiation)
  • Patient refuses further disease-related therapy

A person may qualify for hospice because of dementia (including Alzheimer’s disease) if the person exhibits a combination of the items below:

  • Speech is limited to a few words
  • The person cannot walk, sit or hold up his or her head without help
  • The person cannot eat, dress or bathe without assistance
  • The person has incontinence of bowel and bladder, and he or she has had pneumonia, urinary tract infections or other repeated infections, skin breakdown (ulcers) that won’t heal or recurrent fever after antibiotics
  • The individual has trouble swallowing and is eating and drinking less
  • There has been unintended weight loss in the past six months

NOTE: Although we can evaluate whether a patient may need specialized hospice care, only a licensed physician can certify a patient for hospice care.