REQUEST FOR HOSPICE SERVICES

Rosenthal Community Care Services

The Request for Hospice Services Form by Rosenthal Community Care Services is a professionally structured, non-editable digital document designed for assisted living facilities, RCFE (Residential Care Facilities for the Elderly), ARF (Adult Residential Facilities), board and care homes, and senior care providers. This form supports formal documentation when a resident requests hospice services while remaining in the facility under end-of-life care provisions.

📄 Purpose of This Hospice Services Request Form

This form is used to officially document a resident’s request to receive hospice care services within a licensed care facility. It includes acknowledgment of care preferences, advance directives, and resuscitative decisions, ensuring compliance with facility policies and applicable regulations, including Section 87633-H-1 (Hospice Care for Terminally Ill Residents).

It also provides space for authorization by a Health Care Surrogate Decision Maker, when applicable.

🏥 Form Content Includes

Resident & Facility Information:

• Resident of (Facility Name)
• Room Number
• Resident Identification Details

Hospice Services Request Statement:

• Formal written request for acceptance, admission, or continued stay in the facility while receiving hospice services
• Inclusion of advance directives and/or resuscitative preferences
• Acknowledgment of care decisions made by the resident or authorized surrogate decision maker

Legal & Compliance Acknowledgment:

• Understanding that the request may be withdrawn verbally or in writing at any time
• Facility obligation to make alternative arrangements if request is withdrawn
• Reference to applicable hospice care regulation: Section 87633-H-1

Authorization Section:

• Resident Signature & Date
• Surrogate Decision Maker Signature (if resident is unable to sign)
• Room Number confirmation

⭐ Key Features

• Professional non-editable, print-ready PDF form
• Designed for RCFE, ARF, assisted living, and hospice coordination use
• Supports hospice admission documentation and end-of-life care planning
• Includes surrogate decision maker authorization section
• Structured for regulatory compliance and facility recordkeeping
• Instant digital download (no physical product shipped)
• Clean, professional layout for administrative use

🏡 Ideal For

• Assisted Living Facilities
• Residential Care Facilities for the Elderly (RCFE)
• Adult Residential Facilities (ARF)
• Memory Care Facilities
• Hospice Care Providers
• Board and Care Homes
• Facility administrators, nurses, and case managers

⚡ Why Choose Rosenthal Community Care Services?

Rosenthal Community Care Services provides professionally designed, compliance-focused documentation templates for care facilities. Our forms are built to support assisted living, RCFE, ARF, and hospice coordination workflows, ensuring accurate documentation, clear communication, and regulatory readiness.

📥 Digital Product Notice

This is a non-editable digital PDF form. No physical item will be shipped. After purchase, the file is available for instant download and is ready for immediate printing and facility use.