Hospice Patient Service Request (Approved Partners Only)

Eligibility Criteria (Read First)

To qualify, your hospice must:

Instructions:

Use this form each time you request services for a specific patient/caregiver. This form assumes your hospice has already been approved via the Hospice Organization Initial Application Form.

Acknowledgment:

Our hospice meets all criteria listed above and agrees to provide documentation upon request.

Hospice Information

Hospice name:

Date of submission:

Submitting staff (name/title):

Email/phone:

Coordinator (Holistic Services or Volunteer) name/title:

Email/phone:

Patient & Caregiver Information

Patient name:

Birthday

Month

Day

Year

Age:

Primary language:

Address (for service location):

Primary caregiver name:

Relationship:

Phone/email:

Service Request

Check the holistic services you are requesting HPF to coordinate and fund for this patient/caregiver:

*Monthly request (per patient):

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

Services also requested for caregiver?

Yes

No

If yes, specify:

Patient Status & Needs

Current condition/prognosis (concise):

Expected benefit of requested services (comfort, dignity, symptom relief, relaxation, spiritual support, caregiver relief, etc.):

Special considerations (mobility limits, allergies/sensitivities, religious/cultural preferences, home environment, safety):

Coordination Details

Preferred days/times:

Preferred location:

Patient home

Facility

Other

Facility (name/unit):

Hospice staff present to assist (if any):

Urgency/notes:

Authorization & Attestations

Patient is currently on service with our hospice.

We have obtained patient/caregiver consent for these services.

We understand HPF will arrange and pay providers directly and will coordinate through our designated Coordinator.

Hospice representative name/title:

Signature

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Hospice Patient Service Request (Approved Partners Only)

Eligibility Criteria (Read First)

Hospice Information

Patient & Caregiver Information

Service Request

Patient Status & Needs

Coordination Details

Authorization & Attestations

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