Referrals

Thank you for referring your hospice-eligible patient to VITAS Healthcare. Complete the form below to submit your secure referral.

If you are a clinician who prefers to speak to us in person, call 844.535.9252 to make a referral over the phone. You can also make a referral from the VITAS mobile app, which allows for an instant and secure submission of your patient's face-sheet.

Fields marked with * are required.

Patient's First Name: *

Patient's Last Name: *

Patient's Phone Number:

Patient's Diagnosis:

Facility Name:

Facility State:

Facility City:

Zip Code: *

Patient Contact First Name: *

Patient Contact Last Name: *

Patient Contact Email: *

Patient Contact Phone: *

This Referral is made on behalf of: *

Referrer's First Name: *

Referrer's Last Name: *

Referrer's Email: *

Referrer's Phone Number: *

Title: *

Referral Successfully Received

Our admissions professionals will contact the patient or caregiver to schedule a visit and dispatch a VITAS team member to the bedside. We will contact you with an update in approximately 30 minutes.

If you have immediate concerns, please contact us at 844-535-9592 and reference your confirmation number below.

Confirmation #:

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Please try again, or you can call us at 844.535.9252.

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Referrals

Referral Successfully Received

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