Hospice Agency Questionnaire Form
Date Today
 -
Month
 -
Day
Year
Date
Name of the Hospice Agency
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact Person
First Name
Last Name
Director Name or Administrator Name
First Name
Last Name
Type of agency in terms of services
Home health care
Hospice only
Both
None of the above
Type of agency in terms of profit
For profit
Nonprofit
Goverment
Veterans affair
Other
Is this agency certified by Medicare?
Yes
No
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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Agency Statistics
Rows
Value
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
Hospital
Outpatient Medical Clinics
Assisted Living Facility
Nursing Home
Rehabilitation Facility
Physician's Office
Insurance Provider
Patient, friends, family
Other
What is the business hours of this agency?
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Please provide the time until admission is allowed.
Hour Minutes
AM
PM
AM/PM Option
Kindly explain the process of the agency intake procedure.
Staff Information
Are your nurses certified?
Yes
No
If yes, how many percent of them is certified? (%)
Please put the number only
Does the agency provide pediatric hospice service?
Yes
No
Does the agency belong to a chain or to an affiliation?
Yes
No
If yes, what is the name of the organization?
Does this agency allow palliative treatments like chemotherapy or radiation?
Yes
No
Does this agency allow IV and transfusions?
Yes
No
Does this agency receives patients even if they don't caregiver?
Yes
No
Explain the Quality Assurance process of this agency
Does this agency have case managers who works directly with the patient?
Yes
No
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?
Yes
No
Submit
Should be Empty: