Maxcare Hospice: Referral Checklist
Phone (714) 844-7777 (nurses on call 24/7) · Fax: call for fax · 13800 Arizona St #201, Westminster, CA 92683 · Medicare-certified, CCN 551689
Referring clinician: Date:
- Patient name, date of birth and phone number (send through a secure channel, not this website)
- Signed physician order or referral for hospice evaluation
- Primary terminal diagnosis and relevant secondary or comorbid conditions
- Recent history & physical and progress notes showing decline
- Medication list and allergies
- Recent labs, imaging or other diagnostic results that support the prognosis
- Functional status: PPS or Karnofsky score, ADL dependence, FAST stage for dementia
- Evidence of decline: weight loss, recurrent infections, ER visits or hospitalizations in the past 6 months
- Insurance information (Medicare, Medi-Cal or other) and face sheet
- Advance directive, POLST and code status, if available
- Attending physician who will follow the patient (yes/no), plus contact information
- Caregiver or decision-maker name and phone; preferred language (we have Vietnamese-speaking staff)
- Care setting: home, assisted living, board and care, or skilled nursing facility
Send records only through the secure method our intake team gives you by phone. Vietnamese-speaking staff available.
