Whether you are caring for a patient or a loved one, Pike County Hospice is here to help. We offer secure online forms for physicians and families to request hospice referrals, eligibility reviews, or consultations. Choose the form below to begin a confidential conversation with our hospice team.
Providers
Start a Hospice Referral or Consultation
Use this secure form to request a hospice eligibility review or consultation for your patient. Our caring hospice team will review the information promptly and reach out to coordinate next steps with you, the patient, and their family.
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To help us respond as quickly as possible, please fax supporting documentation, including the patient face sheet, to 573‑324‑5517.
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For questions or urgent needs, please call 573‑324‑2111.
Family Consultation Request
A pressure-free request for information and support.
Completing this form does not mean you are choosing hospice today. It simply opens the door for a conversation. Our team is here to answer questions, provide guidance, and help you understand the support available—so you can make the best decision for your loved one, at the right time.
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We are happy to meet in the way that feels most comfortable for you:
- By phone
- At our office
- In your home or another location of your choice
This secure, HIPAA‑compliant form protects patient privacy. All information submitted is confidential and shared only with the Pike County Hospice care team.
By submitting this secure, HIPAA‑compliant form does not commit you to hospice care. Our goal is simply to provide information, guidance, and support.
Pike County Hospice proudly serves Pike County and surrounding communities with compassionate, community‑based hospice care.