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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, that patient and family are asked to meet with a A-1Hospice Care, Inc, staff member to determine what the patient’s family’s needs are and explain what services we can provide.

For a quick verbal referral please call us (888)650-1616

    Patient Name

    Your Name


    Your Phone

    Your Phone



    Hospital/Nursing Home

    Current Living Arrangements


    Best Person to Contact

    Notes & 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 the government or accrediting organizations and it will be explained to you. The A-1 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 quick referral process. If you would prefer to speak direct with one of our specialists, please use the contact form instead to get in touch with us.

    We provide support to you and your loved ones during an advanced illness.