Hospice Referral Form

Hospice Referral Form — Form Fields

This healthcare template includes 9 fields. Hospice referral form for physicians and case managers to initiate end-of-life care services. Captures diagnosis, functional status, and family contact information for the referral process. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Primary Diagnosis (text, required)
• Referring Physician Name (text, required)
• Patient Functional Status (PPS) (dropdown selection, required) — options: 70-80% — Ambulatory, reduced activity, 50-60% — Considerable assistance needed, 30-40% — Mainly bed-bound, 10-20% — Totally bed-bound
• Does the patient have a DNR order? (multiple choice, required) — options: Yes, No, Pending discussion
• Primary Caregiver / Emergency Contact (text, required)
• Current Medications and Treatment Summary (long text, required)
• Additional Notes for Hospice Team (long text, optional)