Do Not Use This Form for referrals that need immediate attention, as they go to our office general email box. For immediate assistance with referrals 24 hours a day, 7 days a week, call 244-5555.
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Patient Referral Form

Patients Name (required)

Gender:
 female male

Date of Birth:

Marital Status:

Address:
City: State: Zip/postal code:

Patient's Contact Person: (required)
Relationships to Patient :
Contact Phone:
Alternative Phone:

Aware of referral ?
Patient:  yes no
Family:  yes no

Diagnoses:

Referring Physician:

Primary Care Physician, if different:

Physician Office Contact Name:
Phone#:

Please fax (808-244-5557) the following information:
As the checklist includes:

 Face sheet Problem list (medical conditions) Demographic info Lab or image studies with terminal diagnosis Insurance info Most recent office notes Medication list

Thank you very much for your referral!
Hospice Maui staff will call you to confirm receipt of referral.
Call (808) 244-5555 if you don’t hear from us soon!