Referral Forms

Fax or Email Referrals for Hospice Care

Download Hospice Care Referral Form:

Hospice Care Referral Form

Email: intake@hospicesantacruz.org
Fax: (831) 430-9271

Telephone Referrals for Hospice Care

To refer by phone, please contact the Hospice of Santa Cruz County Admissions Department at (831) 430-3000.

Please provide the following information:

• Patient’s name, Patient’s date of birth, Patient’s phone number, Primary contact’s name and phone number, Doctor’s name
• Diagnosis: current and other significant medical data
• Estimated prognosis of six months or less

To discuss eligibility, please call our Admissions Department at (831) 430-3000.

Allscripts Care Management Referral for Hospice Care

If you are an Allscripts Care Management subscriber, you may refer through their portal here.

naviHealth Referral for Hospice Care

You may also refer to us through the naviHealth Portal located here.