Referral Referral Order Physician Information Referring Physician Date Phone Fax Patient Information Patient Name Patient DOB Patient Address Medicare Number Patient Phone Number Coordination & Contacts Primary Contact Number Alternate Phone Number Clinical Orders & Documents Order/Notes Okay for RN to evaluate hospice and admit if appropriate Physician Signature Date 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.
