Hospice Consent Forms

We hope,you have had the opportunity to speak with our hospice specialist or referral coordinator about the services and care that Hospice of the Comforter can provide to your loved and your family residing in the Central Florida area.

Below are forms (PDF format) that are needed for admission to our services. Please click on the link to open the file and either print or download to your computer. Once completed, please fax back to (407) 303-0721. If you need assistance to complete any of the forms, please call us at (407) 682-9090.

1. Consent for Hospice Services:
http://cdn.trustedpartner.com/docs/library/HospiceOfTheComforter2013/Documents/Consent%2C%20Acknowledgement%20and%20Authorizations.pdf

2. Authorization for Communication:
http://cdn.trustedpartner.com/docs/library/HospiceOfTheComforter2013/Documents/Authorization%20for%20Communication.pdf

3. Medicare Benefit Election Form:
http://cdn.trustedpartner.com/docs/library/HospiceOfTheComforter2013/Documents/L2-Hospice%20Benefit%20Election(1).pdf

4. Medicare Secondary Payer Questionnaire:
http://cdn.trustedpartner.com/docs/library/HospiceOfTheComforter2013/Documents/L3-Medicare%20Secondary%20Payer%20Questionnaire.pdf

5. Do Not Resuscitate Order (DNRO):
http://cdn.trustedpartner.com/docs/library/HospiceOfTheComforter2013/Documents/L6-DNRO.pdf

6. Health Care Proxy Designation:
http://cdn.trustedpartner.com/docs/library/HospiceOfTheComforter2013/Documents/L8-Health%20Care%20Proxy%20Designation%20and%20Acceptance.pdf

Fax Completed Forms to (407) 303-0721
or mail to Hospice of the Comforter, Attn: Referrals Dept.,
605 Montgomery Road, Altamonte Springs, FL 32714

You may call usĀ at 407-682-9090 anytime.


24/7 Patient Support: (407) 379-0311
480 W. Central Parkway, Altamonte Springs, Florida 32714