Page 17 - Hospice Savannah
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                              Hospice Savannah Referral Form
1352 Eisenhower Drive, Savannah, GA 31406
Main (912) 355.2289 Referral Center (912) 629.1088 Fax (912) 298.0306
Patient: .................................................................................................... SSN: ..................................................................................... DOB: .............................................. Insurance name and policy #: ..................................................................................... Orders:
Hospice Savannah, Inc. consult. Evaluate patient and admit to hospice or palliative care services if appropriate
Specific orders/instructions:.......................................................................................................................................... .................................................................................................................................................................................................................. ..................................................................................................................................................................................................................
Yes, I will follow this patient while on hospice services
No, I will not follow this patient while on hospice services and Hospice Savannah’s Medical Director will assume responsibility.
Referring physician signature:....................................... Date:........................................................................................... Terminal diagnosis*: ........................................................................................................................................................................ Referral source/Physician:.................................................. Contact #:...............................................................................
*Please send the following documentation to support a hospice diagnosis if available and applicable: most recent history & physical; visit notes; weight history; demographic/facesheet; most recent lab/diagnostic test results (i.e. albumin, echo, EKG, pO2, pCO2, FEV1, etc.) & current medication list/MAR.
Thank you for allowing Hospice Savannah, Inc. to provide services to your patient and their family. Our office will update you regarding the referral status after meeting with them.
The only hospice to have earned the Gold Seal of Approval® from The Joint Commission
                             






















































































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