Hospice Eligibility Form – Affinity Care of Florida

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Hospice/Palliative Care Screening Form
Note: Please do not enter the patient’s name or any other Personal Identifiable Information (PII) into this form. Just enter basic information as it applies to your situation, and we will reach back out for the next step.
Patient's Age*
Patient's County*
Patient's State*
Patient's Condition*

ImprovingDecliningStable
Patient's Primary Diagnosis*
Does the patient suffer from any of the following conditions (check all that apply)

Constant FallsParkinson'sUTIEnd Stage Renal DiseaseCancerCongestive Heart Failure (CHF)DementiaAlzheimer'sOther
What cancer stage does the patient have?*

IIIIIIV
Is the patient currently*

At homeIn hospitalIn nursing homeIn assisted living
How does the patient currently eat?*

ManualFeeding tubeSelf
Is the patient bedridden or otherwise immobile?*

YesNo

Note: Please do not enter the patient’s name or any other Personal Identifiable Information (PII) into this form. Just enter basic information as it applies to your situation, and we will reach back out for the next step.
Your Name*

First NameLast Name
Your Phone*
Please enter a valid phone number.
Your Email*
example@example.com
Should be Empty:

Hospice/Palliative Care Screening Form