Active Hospice Care, Inc. Patient Referral Form

Anyone can request hospice services for hospice care. In fact, some patients refer themselves. We will contact the patient’s physician/caregiver to ensure that hospice care is the best choice. Once it has been decided to consider our care, the patient and family are asked to meet with a Active Hospice Care, Inc. staff member to determine what the patient’s and family’s needs are and explain what services we can provide.

For a quick verbal referral please call us: (866) 496-CARE

Patient Information

Patient’s Name: (required)

Patient’s Address:



Patient’s Phone Number:

Patient’s Primary Physician/Caregiver:


Current Living Arrangements:

Who would be the best person to contact:

Your Information

Your Organization:

Your Email Address:

Your Name:

Your Phone Number:



Nursing Home:

Family member of Friend:

Assissted Living Facility:

Notes or Remarks:

The initial visit can be completed at the patient’s home, in the hospital, assisted living facility, long-term care facility, or wherever the patient and family feel it is most convenient. On admission, the patient and family are asked to sign various forms to enter into the program. These forms are required by government or accrediting organizations, and will be explained to you. The Active Hospice Care, Inc. team develops a plan of care that meets each patient’s individual needs.

Because we value your time, the following inquiry form is designed to offer a quick and convenient way to initiate the referral process. If you would prefer to speak directly with one of our  specialists, please use the contact form instead to get in touch with us.