How Can We Help You?

Refer/Admit a Patient

Referring a patient for Skirball Hospice services is easy.

If you are a healthcare provider and wish to refer your patient for services from Skirball Hospice, simply fill out our clinical referral form below.

If you require additional admission information, please contact us at 877.774.3040 or by e-mail at SkirballHospice@jha.org and you will be contacted shortly.

Admissions Criteria

There are three main eligibility criteria that need to be met in order to receive Skirball Hospice services: the patient must be terminally ill with a medical prognosis of six months, the patient is no longer seeking curative treatment, and the patient and family are aware of the terminal illness and understand and accept the hospice philosophy of care.

Items that are required are marked with an asterisk (*).

Patient Referral Form

Patient's First Name: *

Patient's Last Name: *

Address:

City:

State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusettes Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Patient's Phone Number: *

Phone Type:

Home

Work

Mobile

*

Attending Physician:

Primary Diagnosis:

Caregiver's Name:

Relationship:

Caregiver's Phone Number:

Your Name: *

Your Return Phone Number: *

Phone Type:

Home

Work

Mobile

*

Your E-mail Address: *

Your Relationship to the Patient:

Comments: