Patients with any of the following illnesses may be appropriate for a hospice referral once eligibility criteria are met:

• Amyotrophic Lateral Sclerosis (ALS)
• Cancer
• HIV/AIDS Stroke

   In addition, patients with the following end-stage diseases may also be hospice-appropriate:

• Alzheimer’s
• Cardiovascular Disorder
• Dementia
• Renal Diseases
• Liver Disease
• Lung Disease

Eligibility Criteria
  Patients must meet the following eligibility criteria to be appropriate for hospice care:

• Patients with a prognosis of six months or less if the disease runs its normal course.
• Hospice can continue after six months as long as the patient continues to meet eligibility criteria.
• Prognosis is certified by community and hospice physician.
• Patient and family desire palliative care as opposed to curative.

  If any questions regarding eligibility, please contact:
Dr. Mark Mathurin
602-216-2273

  You can also make a referral by printing the supplied form below and faxing it to:
602-443-5397.

Serenity Referral Evaluation Worksheet