Refer a Patient

How to Make a Referral

Anyone can make a referral to Calvary Hospital Hospice by calling either of the two phone numbers listed below.
After a referral is made to Calvary Hospital Hospice, the nurse contacts the patient and/or family to schedule a time to meet.
The ultimate decision regarding the acceptance of hospice care is made by the patient and family/ caregiver.

Insurance and Payment Options

As a Medicare- and Medicaid-approved agency, VNSNY accepts all forms of payment—including government reimbursements, commercial insurance, and out-of-pocket payments. Please note that Medicare and Medicaid have precise criteria that must be met for eligibility.

Refer a Patient Online

Patient Information

First Name (required)

Middle Name

Last Name (required)

Address (required)

Address (line 2)

City (required)

State (required)

Zip (required)

Phone Number (required)

Birth Date (required)

Sex (required)

Marital Status (required)

Social Security Number (required)

Medicare

Medicaid

Other Insurance

Policy Number (required)

Contact Information

Primary Family Contact (required)

Relationship (required)

Phone Number (required)

Alternate Contact (required)

Relationship (required)

Phone Number (required)

Family Aware of Referral (required)
YesNo

Diagnosis Information

Primary Diagnosis (required)

Other Past Medical History (required)

Allergies (required)

Current Treatments (required)

Referral Information

Referral Source (MD office/Hospital/Agency) (required)

SW/CM Name (required)

Phone Number (required)

Referring Physician (required)

Phone Number (required)

Fax Number

Referral Completed by (required)

Phone Number

How to Make a Referral

Insurance and Payment Options

Refer a Patient Online

Patient Information

Contact Information

Diagnosis Information

Referral Information

Calvary Hospice

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