Hospice Agency Questionnaire Form
Name of the Hospice Agency
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Primary Contact Person
Director Name or Administrator Name
Type of agency in terms of services
Home health care
None of the above
Type of agency in terms of profit
Is this agency certified by Medicare?
If yes, what is the Medicare Provider Number?
Please provide the list of services your agency is currently offering
Kindly upload a copies of the updated federal and state survey reports
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Choose a file
How many patients does this agency served right now in this location?
How many patients were admitted for this calendar year?
How many patients were discharged for this calendar year?
Average admission daily
Average discharge daily
Average length of stay of the patients
What is the most common medical diagnosis of the patients in this hospice?
Source of Referral
Outpatient Medical Clinics
Assisted Living Facility
Patient, friends, family
What is the business hours of this agency?
Please provide the time until admission is allowed.
Kindly explain the process of the agency intake procedure.
Are your nurses certified?
If yes, how many percent of them is certified? (%)
Please put the number only
Does the agency provide pediatric hospice service?
Does the agency belong to a chain or to an affiliation?
If yes, what is the name of the organization?
Does this agency allow palliative treatments like chemotherapy or radiation?
Does this agency allow IV and transfusions?
Does this agency receives patients even if they don't caregiver?
Explain the Quality Assurance process of this agency
Does this agency have case managers who works directly with the patient?
What kind of case management process are you using? Kindly explain below:
Who is the primary contact person or department that is responsible for communicating with insurers?
Does the agency have a process in terms of handling complain?
Should be Empty: