KAQ-Health-Hospice-Referral-Form

For more information on the services we provide visit:
Karen Ann Quinlan Hospice - Healthcare Professionals
Please complete this form click the submit button below. You may send supporting documents via fax to: 973-383-6889 or use the upload link below. Need to speak to a team member? Call 973-383-0115

All fields marked with an asterisk (*) are required.
Contact Name*
Referral Source*
Phone*
Email*
example@example.com
Patient Clinical Information
Has Patient and/or family been informed about the hospice referral?*

YesNo
Proposed Terminal Disgnosis
Reason for Hospice Referral**
To expedite referral, please send supporting documentation

Patient Face SheetPalliative Provider NotesHistory & PhysicalMost Recent Labs or Reports (ie.e Echo, Pathology, MRI, etc.)Last 2-3 Office Visit Notes
Patient Contact Information
Patient Name*
DOB*
Gender*
Phone*
Email
example@example.com
Please send demographic sheet and insurance information or complete below.
Type of residence where care will be delivered*

HomeNursing HomeAssisted LivingGroup HomeOther
Address*

Address

Street Address Line 2

CityState / Province

Zip
Phone*
Will the patient be the primary point of contact throughout treatment?*

YesNo
If no, please provide information of primary point of contact below.
Name
Phone
Contact Email
example@example.com
Relationship to Patient
Payor Information

Complete all that apply
Medicare No.
Medicaid No.
Other Carrier
Policy Number
Charity Care

Charity Care
Provider Information
Name of Ordering Provider*
Select one:

MDPANP
Phone*
If patient consents, will the provider follow this patient for hospice?*

YesNo
Order for Hospice Evaluation and Treatment
Based on my clinical expertise, I certify that this patient has a terminal illness with a prognosis of six (6) months or less if the disease follows its typical course.*

Yes
Provider Signature*

Clear
Date*

MonthDayYear
Date
Upload supporting documents. Please upload documents before submitting completed form.

Cancelof
Palliative Performance Scale (PPS) and Hospice

The Palliative Performance Scale (PPS)1 can inform decisions about a patient’s hospice eligibility by helping clinicians recognize a patient's functional decline. For oncology patients, a PPS score of 70% or below may indicate hospice eligibility. For most other disease types, a patient with a PPS score of 50% or below may be hospice-eligible.
Use this tool to recognize functional decline quickly and inform decisions about your patient's eligibility.
For most disease types, a patient with a PPS score of 50% or below may be hospice-eligible. 70% or below may indicate hospice or palliative care eligibility.

As a patient nears the end of life, it can be tough to find the right time to adjust their care. Although a physician’s professional judgment remains the key factor, the Palliative Performance Scale (PPS) can help in the process.

The PPS is a validated and reliable tool that can be used to assess your patient’s ability to function and determine how to move toward the end of life, including when to have goals-of-care conversations with patients and families.
*Please note that this calculator is an approximation of PPS and does not substitute clinical judgment.
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Patient Clinical Information

Patient Contact Information

Payor Information

Provider Information

Order for Hospice Evaluation and Treatment

Palliative Performance Scale (PPS) and Hospice