{"product_id":"request-for-hospice-services","title":"REQUEST FOR HOSPICE SERVICES","description":"\u003cp data-start=\"63\" data-end=\"100\"\u003e\u003cstrong data-start=\"63\" data-end=\"100\"\u003eRosenthal Community Care Services\u003c\/strong\u003e\u003c\/p\u003e\n\u003cp data-start=\"102\" data-end=\"581\"\u003eThe \u003cstrong data-start=\"106\" data-end=\"143\"\u003eRequest for Hospice Services Form\u003c\/strong\u003e by \u003cstrong data-start=\"147\" data-end=\"184\"\u003eRosenthal Community Care Services\u003c\/strong\u003e is a professionally structured, \u003cstrong data-start=\"217\" data-end=\"250\"\u003enon-editable digital document\u003c\/strong\u003e designed for \u003cstrong data-start=\"264\" data-end=\"431\"\u003eassisted living facilities, RCFE (Residential Care Facilities for the Elderly), ARF (Adult Residential Facilities), board and care homes, and senior care providers\u003c\/strong\u003e. This form supports formal documentation when a resident requests hospice services while remaining in the facility under end-of-life care provisions.\u003c\/p\u003e\n\u003chr data-start=\"583\" data-end=\"586\"\u003e\n\u003ch3 data-section-id=\"2y2eks\" data-start=\"588\" data-end=\"642\"\u003e📄 Purpose of This Hospice Services Request Form\u003c\/h3\u003e\n\u003cp data-start=\"643\" data-end=\"1019\"\u003eThis form is used to officially document a resident’s request to receive \u003cstrong data-start=\"716\" data-end=\"773\"\u003ehospice care services within a licensed care facility\u003c\/strong\u003e. It includes acknowledgment of care preferences, advance directives, and resuscitative decisions, ensuring compliance with facility policies and applicable regulations, including \u003cstrong data-start=\"953\" data-end=\"1018\"\u003eSection 87633-H-1 (Hospice Care for Terminally Ill Residents)\u003c\/strong\u003e.\u003c\/p\u003e\n\u003cp data-start=\"1021\" data-end=\"1125\"\u003eIt also provides space for authorization by a \u003cstrong data-start=\"1067\" data-end=\"1107\"\u003eHealth Care Surrogate Decision Maker\u003c\/strong\u003e, when applicable.\u003c\/p\u003e\n\u003chr data-start=\"1127\" data-end=\"1130\"\u003e\n\u003ch3 data-section-id=\"1fh4w33\" data-start=\"1132\" data-end=\"1162\"\u003e🏥 Form Content Includes\u003c\/h3\u003e\n\u003cp data-start=\"1164\" data-end=\"1202\"\u003e\u003cstrong data-start=\"1164\" data-end=\"1200\"\u003eResident \u0026amp; Facility Information:\u003c\/strong\u003e\u003c\/p\u003e\n\u003cul data-start=\"1203\" data-end=\"1286\"\u003e\n\u003cli data-section-id=\"gqg9xw\" data-start=\"1203\" data-end=\"1234\"\u003eResident of (Facility Name)\u003c\/li\u003e\n\u003cli data-section-id=\"18x902c\" data-start=\"1235\" data-end=\"1250\"\u003eRoom Number\u003c\/li\u003e\n\u003cli data-section-id=\"w35riu\" data-start=\"1251\" data-end=\"1286\"\u003eResident Identification Details\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp data-start=\"1288\" data-end=\"1329\"\u003e\u003cstrong data-start=\"1288\" data-end=\"1327\"\u003eHospice Services Request Statement:\u003c\/strong\u003e\u003c\/p\u003e\n\u003cul data-start=\"1330\" data-end=\"1620\"\u003e\n\u003cli data-section-id=\"kuyonq\" data-start=\"1330\" data-end=\"1454\"\u003eFormal written request for acceptance, admission, or continued stay in the facility while receiving \u003cstrong data-start=\"1432\" data-end=\"1452\"\u003ehospice services\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003cli data-section-id=\"1ygfvob\" data-start=\"1455\" data-end=\"1523\"\u003eInclusion of advance directives and\/or resuscitative preferences\u003c\/li\u003e\n\u003cli data-section-id=\"s0dabx\" data-start=\"1524\" data-end=\"1620\"\u003eAcknowledgment of care decisions made by the resident or authorized surrogate decision maker\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp data-start=\"1622\" data-end=\"1662\"\u003e\u003cstrong data-start=\"1622\" data-end=\"1660\"\u003eLegal \u0026amp; Compliance Acknowledgment:\u003c\/strong\u003e\u003c\/p\u003e\n\u003cul data-start=\"1663\" data-end=\"1903\"\u003e\n\u003cli data-section-id=\"24dl98\" data-start=\"1663\" data-end=\"1749\"\u003eUnderstanding that the request may be withdrawn verbally or in writing at any time\u003c\/li\u003e\n\u003cli data-section-id=\"1612pcc\" data-start=\"1750\" data-end=\"1830\"\u003eFacility obligation to make alternative arrangements if request is withdrawn\u003c\/li\u003e\n\u003cli data-section-id=\"6soigc\" data-start=\"1831\" data-end=\"1903\"\u003eReference to applicable hospice care regulation: \u003cstrong data-start=\"1882\" data-end=\"1903\"\u003eSection 87633-H-1\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp data-start=\"1905\" data-end=\"1933\"\u003e\u003cstrong data-start=\"1905\" data-end=\"1931\"\u003eAuthorization Section:\u003c\/strong\u003e\u003c\/p\u003e\n\u003cul data-start=\"1934\" data-end=\"2063\"\u003e\n\u003cli data-section-id=\"1navu7c\" data-start=\"1934\" data-end=\"1963\"\u003eResident Signature \u0026amp; Date\u003c\/li\u003e\n\u003cli data-section-id=\"1u47i6h\" data-start=\"1964\" data-end=\"2034\"\u003eSurrogate Decision Maker Signature (if resident is unable to sign)\u003c\/li\u003e\n\u003cli data-section-id=\"18rx8l7\" data-start=\"2035\" data-end=\"2063\"\u003eRoom Number confirmation\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003chr data-start=\"2065\" data-end=\"2068\"\u003e\n\u003ch3 data-section-id=\"1tuu1xi\" data-start=\"2070\" data-end=\"2090\"\u003e⭐ Key Features\u003c\/h3\u003e\n\u003cul data-start=\"2091\" data-end=\"2540\"\u003e\n\u003cli data-section-id=\"14j1nk8\" data-start=\"2091\" data-end=\"2146\"\u003eProfessional \u003cstrong data-start=\"2106\" data-end=\"2144\"\u003enon-editable, print-ready PDF form\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003cli data-section-id=\"1usofi2\" data-start=\"2147\" data-end=\"2224\"\u003eDesigned for \u003cstrong data-start=\"2162\" data-end=\"2222\"\u003eRCFE, ARF, assisted living, and hospice coordination use\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003cli data-section-id=\"14aralj\" data-start=\"2225\" data-end=\"2299\"\u003eSupports hospice admission documentation and end-of-life care planning\u003c\/li\u003e\n\u003cli data-section-id=\"1r9hd7v\" data-start=\"2300\" data-end=\"2359\"\u003eIncludes surrogate decision maker authorization section\u003c\/li\u003e\n\u003cli data-section-id=\"fn4pvj\" data-start=\"2360\" data-end=\"2427\"\u003eStructured for regulatory compliance and facility recordkeeping\u003c\/li\u003e\n\u003cli data-section-id=\"w9hads\" data-start=\"2428\" data-end=\"2486\"\u003eInstant digital download (no physical product shipped)\u003c\/li\u003e\n\u003cli data-section-id=\"4jndbo\" data-start=\"2487\" data-end=\"2540\"\u003eClean, professional layout for administrative use\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003chr data-start=\"2542\" data-end=\"2545\"\u003e\n\u003ch3 data-section-id=\"1594ux1\" data-start=\"2547\" data-end=\"2565\"\u003e🏡 Ideal For\u003c\/h3\u003e\n\u003cul data-start=\"2566\" data-end=\"2824\"\u003e\n\u003cli data-section-id=\"gf3lpy\" data-start=\"2566\" data-end=\"2596\"\u003eAssisted Living Facilities\u003c\/li\u003e\n\u003cli data-section-id=\"1l3dfo2\" data-start=\"2597\" data-end=\"2651\"\u003eResidential Care Facilities for the Elderly (RCFE)\u003c\/li\u003e\n\u003cli data-section-id=\"6w4hz9\" data-start=\"2652\" data-end=\"2690\"\u003eAdult Residential Facilities (ARF)\u003c\/li\u003e\n\u003cli data-section-id=\"1s5v07z\" data-start=\"2691\" data-end=\"2717\"\u003eMemory Care Facilities\u003c\/li\u003e\n\u003cli data-section-id=\"ndf5ac\" data-start=\"2718\" data-end=\"2744\"\u003eHospice Care Providers\u003c\/li\u003e\n\u003cli data-section-id=\"1pj4re8\" data-start=\"2745\" data-end=\"2769\"\u003eBoard and Care Homes\u003c\/li\u003e\n\u003cli data-section-id=\"ckt2pi\" data-start=\"2770\" data-end=\"2824\"\u003eFacility administrators, nurses, and case managers\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003ch3 data-section-id=\"1l93ltr\" data-start=\"3210\" data-end=\"3263\"\u003e⚡ Why Choose Rosenthal Community Care Services?\u003c\/h3\u003e\n\u003cp data-start=\"3264\" data-end=\"3582\"\u003e\u003cstrong data-start=\"3264\" data-end=\"3301\"\u003eRosenthal Community Care Services\u003c\/strong\u003e provides \u003cstrong data-start=\"3311\" data-end=\"3382\"\u003eprofessionally designed, compliance-focused documentation templates\u003c\/strong\u003e for care facilities. Our forms are built to support \u003cstrong data-start=\"3435\" data-end=\"3501\"\u003eassisted living, RCFE, ARF, and hospice coordination workflows\u003c\/strong\u003e, ensuring accurate documentation, clear communication, and regulatory readiness.\u003c\/p\u003e\n\u003chr data-start=\"3584\" data-end=\"3587\"\u003e\n\u003ch3 data-section-id=\"1rrppyt\" data-start=\"3589\" data-end=\"3620\"\u003e📥 Digital Product Notice\u003c\/h3\u003e\n\u003cp data-start=\"3621\" data-end=\"3812\"\u003eThis is a \u003cstrong data-start=\"3631\" data-end=\"3664\"\u003enon-editable digital PDF form\u003c\/strong\u003e. No physical item will be shipped. After purchase, the file is available for instant download and is ready for immediate printing and facility use.\u003c\/p\u003e","brand":"Rosenthal Community Care Services","offers":[{"title":"Generic","offer_id":51260794208562,"sku":null,"price":3.99,"currency_code":"USD","in_stock":true},{"title":"Branded","offer_id":51260794241330,"sku":null,"price":7.99,"currency_code":"USD","in_stock":true}],"url":"https:\/\/rosenthalcommunitycare.com\/products\/request-for-hospice-services","provider":"Rosenthal Community Care Services","version":"1.0","type":"link"}