HOSPICE REFERRAL

Hospice Referral Form

If you are interested in receiving services for yourself, a family member, or a loved one, please fill out the form below.

For privacy and safety reasons, please do not include any personal health information. If you have questions, need more information, or require immediate assistance, please call us at 803-329-1500.

     

    I am requesting services for:

    Physician Referrals

    There are two simple ways to refer your patient to Hospice & Community Care:

    Fax the referral

    803-329-1695

    Call our office

    803-329-1500

    Please include with fax:

    • History and Physical (H&P)
    • Progress Notes
    • Medication List

    Please include with fax:

    • Fax Cover Letter (download here)
    • Referral Form (download here)
    • Patient Demographic Sheet
    • History and Physical (H&P)
    • Progress Notes
    • Medication List
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