Refer a Patient

Make a Referral

Three easy ways to refer a patient:

  • Fill in the form for the referral below and once submitted our qualified team will start the process.
  • You can download the form and fax or email it us.
  • You can also call in the referral, you can contact us at 323-653-0544 with following information:
    • Patient full name
    • Phone number
    • Physician name
    • Diagnosis- current H&P

If you are referring from Acute Hospital Request Victoria hospice services on your discharge orders when ordering hospice services.


Does your patient qualify?

View Eligibility Criteria

Hospice Referral Form
Admission Consent Form
Consent for Primary Caregiver Form
Hospice Notification Non-Covered Items
Consent for Election Medicare Benefit
Patient Evacuation Plan

8797 Beverly Blvd., Suite 310
West Hollywood, CA 90048

(323) 653-0544