Visiting Nurse Service

 
 
Hospice Referral Form
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  5. Patient Name
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  9. Date of Birth
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  11. Does patient live alone?


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  12. Does another person need to be present during initial evaluation visit?


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  13. If "yes", Contact Name
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  14. Contact Phone
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  15. Terminal diagnosis(es) for which hospice is being ordered
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  16. Pertinent medical/surgical history that clarifies appropriateness for hospice
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  17. Allergies
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  18. Pertinent social history
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  19. Prognosis



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  20. If "Other," length of time
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  21. Health Care Proxy completed


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  22. If "yes," name
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  23. If "no," explain
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  24. Relationship
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  25. Phone
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  26. Other services requested



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  27. Enter the letters or numbers you see on the right into the box below it*
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  28.  

Determining Eligibility for Hospice Care
 

  • Hospice is a comprehensive service available to patients and their families who have a life expectancy of six months or less.
  • Medicare A, Medicaid and most insurances have hospice benefits.
  • Guidelines are based on Local Coverage Determination (LCD) for Hospice eligibility used by National Government Services (NGS), a Medicare fiscal intermediary.
  • Sometimes a patient does not "fit" into the guidelines but still has a life expectancy of six months or less and therefore is eligible for hospice.
  • Predicting a life-expectancy of six months or less usually involves a significant, documented deterioration in physical status/function, such as weight loss or decreased function and/or an end-stage disease.
  • Decline may also be due to refusal of treatments, medications or hospitalization aimed at improving or stabilizing an advanced disease.
  • A patient can be appropriate for hospice even without a specific end-stage disease.
  • If your patient does better than initially expected, he or she may get discharged from hospice, yet can always get hospice service at a later time when more appropriate. There is no penalty for early referral.
  • Please call us if yo think your patient may benefit from hospice service. We would be happy to evaluate your patient for hospice eligibility. Hospice medical director consultation services are also available.

Visiting Nurse Service of Rochester and
Monroe County, Inc.
(585) 787-2233
(800) 724-5727

2180 Empire Boulevard • Webster, NY 14580

 

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  1. VNSDear Patient:

    We like to recognize VNS staff who are living our I CARE values and are providing you extraordinary care and service. Please let us know if you see our employees acting with Integrity, Compassion, Accountability, Respect, Excellence.



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  9. I CARE ~ Integrity, Compassion, Accountability, Respect, Excellence