Individual Patient / Caregiver Application

Eligibility Criteria (Read First)

To qualify, your hospice must:

Important:

HPF does not give money to patients or hospices. HPF coordinates and pays approved providers directly, in collaboration with your hospice’s Coordinator. Services may also be provided to the primary caregiver. Final service types and number of sessions per month are at HPF’s discretion.

Applicant & Patient Information

Applicant Name:

Relationship to patient:

Self

Family

Friend

Other

Applicant Phone:

Applicant Email:

Patient Name:

Date of birth:

Month

Day

Year

Age

Address

Primary Language:

Hospice agency (if enrolled):

Hospice contact (name/title):

Contact email/phone:

Demographics

(for program equity & impact tracking)

Caregiver present:

Yes

No

Ownership:

Locally Owned

Other

Caregiver name (if applicable):

Relationship (if applicable):

Service Request

*Monthly request (per patient):

*(Final number/type of sessions will be determined by HPF at its discretion.)

Patient Needs

Briefly describe the patient’s current condition and how these services may help (comfort, dignity, connection, symptom relief, caregiver support, etc.):

Special considerations (mobility, allergies/sensitivities, religious/cultural preferences, safety, pets in home, etc.):

Authorization & Acknowledgments

I understand HPF does not provide funds to me or my hospice; HPF will arrange and pay providers directly.

I authorize HPF and my hospice (if applicable) to coordinate scheduling and services.

I consent to non-identifying information being used for program reporting and improvement.

Signature

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Individual Patient / Caregiver Application

Eligibility Criteria (Read First)

Applicant & Patient Information

Demographics

Service Request

Patient Needs

Authorization & Acknowledgments

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