If you or a loved one is experiencing significant health challenges, you may be wondering if hospice care is the right choice. This form is designed to help you determine eligibility for our hospice services.

Eligibility Requirements: Life-limiting illness | Patient has a declining functional status

End Stage Diagnosis
Hospice is often associated with cancer, but any patient with any advanced illness is eligible for hospice. These may include, but are not limited to:

Metastatic Malignancies | Heart Disease | Kidney Disease | Liver Disease | Lung Disease | Stroke and/or Coma | AIDS | Neurological Diseases (Alzheimer's, Parkinson's, Dementia, etc.) | Lou Gehrig's (ALS) Disease

In addition, those experiencing serious multi-symptom deterioration, frequent emergency room visits and/or hospitalizations, or discontinuing aggressive treatment may also be eligible for hospice care.

Generally it is time for hospice when doctors are offering a prognosis of 6 months or less. It is better to begin hospice care early rather than late. Many people are referred too late to fully benefit from all the services offered through hospice. It is not necessary to be home bound to receive hospice care.

Please take a moment to complete the questions below. By checking the statements that apply, you can gain a better understanding of whether hospice care may be appropriate for your situation. Once you’ve filled out the form, a member of our team will reach out to discuss your needs and how we can support you.