Referrals

BLUEVINE HOSPICE

We ceaselessly strive for better quality of life out comes for our patients.

Refer Someone

Making a referral

Seeking specialized hospice care services shouldn't be limited to specific disease stages. Whether you're a healthcare professional or a family member, you can refer a patient to us at any point. However, research has shown that early referrals can result in better quality of life outcomes. A prompt referral means we can spend more time communicating with patients and loved ones, truly understanding their needs and seamlessly coordinating their care.

Determining when a patient is medically suitable for hospice care can be a complex decision. Thankfully, there are several telltale signs and symptoms to look out for:

Symptoms that are uncontrolled or chronic and negatively affect quality of life
A gradual decline in functional ability
Unintentional and progressive weight loss exceeding 10% in the last six months
Multiple chronic health conditions
Needs assistance with most daily activities
Frequent infections
Repeated emergency department visits or hospitalizations
Wounds that do not heal.

Determine your patient's eligibility for hospice care through our support, or allow us to assist you in initiating the discussion with them. Our Registered Nurses will evaluate and design a customized care plan that is most suitable for your patient's requirements.

Ready to explore hospice care for yourself or a loved one? Fill out the simple referral form below, or call us at (281) 751-8333.

Hospice Care Referral Form

Name of Referrer

Phone Number

Relation to Patient

Patient Information

First Name

Middle Name

Last Name

Select a date

Is the family aware that a referral is being made to Bluevine Hospice?

Yes

Who should we call to schedule the visit?

Name

Relationship to Patient

Phone Number

Patient's Current Location

Patient's Home Address

Is the patient in the clinic/hospital at the time the referral is being called in?

Yes

Insurance Number

Is patient able to make own decisions and sign own consents?

Yes

Referring Physician

Attending Physician

Who should we call to schedule the visit?

(i.e. wait for call for referral visit until siblings have been spoken to, facility nurse desired to be present for visit, wait for family member in lobby prior to visit)

Add answer here

Brief history of progressive illness

Add answer here

You may attach the face sheet or other medical information:

Upload File

Thanks for submitting!

Love and Comfort when it Matters the most

Tel: (281) 751-8333 Fax: (281) 860-2030

Referrals

BLUEVINE HOSPICE

We ceaselessly strive for better quality of life out comes for our patients.

Refer Someone

Making a referral

Hospice Care Referral Form

Patient Information

Who should we call to schedule the visit?

Who should we call to schedule the visit?

Brief history of progressive illness

For Referrals Call (832) 751-8333