Best Home Health and Hospice Service
Referring Physician
Date
Phone
Fax
Patient Name
Patient DOB
Patient Address
Medicare Number
Patient Phone Number
Primary Contact Number
Alternate Phone Number
Order/Notes
Okay for RN to evaluate hospice and admit if appropriate
Physician Signature
I want to serve as the attending physician for the patient during services I want the Hospice Medical Director to serve as the attending physician for the patient during services.
