Required Infomation

Has hospice been discussed with the patient/family ? YesNo

Supporting Document

If you have the following supporting documentation, please provide as appropriate :

• Patient Face Sheet (Demographics)
• Discharge Summary
• Medicare/Medicaid/Commercial
• Pathology Reports
• Last Visit Note Insurance Card
• History and Physical
• Labs
• Additional Information

I have attached scanned documents with this FormPlease send representative to collect documents.
Attach file, please compress all file into one zip file, filesize max 2mb :

Orders

Please Choose one :
Hospice medical director to assume care of the patient.Doctor (provide name below) will remain attending physician.Doctor (provide name below) will remain attending physician with hospice medical director to assist with signs & symptoms management

For physicians: Check box below to authorize us to evaluate and admit patient, if eligible.

I authorize PPCH to evaluate and admit patient