Referrals


From physicians to friends, family members, or neighbors, anyone can make a referral for hospice care. Hometown Hospice team members are available by phone, 24 hours a day, seven days a week. When a referral is made, a Hometown Hospice representative will schedule a visit with the patient and/or family. Care can usually begin same day of a referral.

How to refer

Referrals to Hometown Hospice can be made 24 hours a day, 7 days a week. It is an easy 3 step process to make a referral.

Step 1: Place the call to Hometown Hospice.
Step 2: Our staff will contact all responsible parties to coordinate family consultation and/or patient assessments.
Step 3: Our hospice team consults, evaluates and initiates care, if appropriate.

Or submit the following form

Hospice Referral Form

Fields marked with an * are required
If someone you know may be in need of hospice care, please submit the following form with your information (the referrer) and the patient's information. We will have one of our Hospice Liaisons contact you and/or the patient to assess hospice eligibility and admit the patient if necessary.

Your Information






Patient Information






Neurological (CVA, Parkinson's, ALS)Renal DiseaseCardiacHIVDementia/Alzheimer'sCOPD/Lung DiseaseLiver DiseaseOtherUnknown