referral2 - Triage Hospice

Referral

Our team will work with you to verify coverage and guide you through the financial process, so you can focus on what matters most.

Referral Form

First Name

Last Name

Date of Birth

Social Security Number

Gender

Primary Language

Address

Patient Phone Number

Primary Contact Name

Primary Contact Number

Relationship to Patient

Insurance Details

Medicare Number (MBI)

Medicaid ID Number

State of Medicaid Coverage

Other Insurance (if applicable)

Insurance Plan

Policy Number

Group Number

Additional Information

Does Patient have an Advance Directive or DNR Order?

(If yes, please attach documentation)

Upload Document

Referral Details

Referring Physician/Provider Name

Referral Facility Name

Referral Phone Number

Referral Fax Number

Diagnosis

Estimated Start Date for Hospice Care

Location of Care

Referral Submitted By:

Full Name

Title

Phone Number

Fax Number

Referral Options:

We offer multiple ways to make a referral, ensuring a seamless process for you and your loved ones. You can submit a referral online, by phone, or via email, and our team will guide you through the next steps with care and support.

Call: 281-975-5188

Fax: 281-975-5158

Email: info@triagehospice.com

How To Make A Referral

Referrals can be made by anyone who recognizes the need for hospice care, including:

Family Members
Patients
Physicians or Nurse Practitioners
Hospital Discharge Planners
Case Managers / Social Workers
Spiritual Advisors or Clergy

Triage Hospice LLC is an equal opportunity employer and does not discriminate in the provision of services or employment based onr ace, national origin, color, religion, sex, age, genetics or disability pursuant to Title VI of the Civil Rights ACT of 1964 Section 504 of Rehabilitation Act of 1973 and the Age Discrimination Act of 1975.

Complaints? Please call:

City of Houston Department of Health:
832-393-4220

Texas Health and Human Services:
1-800-458-9858