Horizon Hospice: Secure Request for More Information
If you, or someone you know might benefit from our services, please complete the information below and we will give them a call.
Privacy note: This information will be encrypted and stored on a password-protected server site for HIPAA protection. It cannot be intercepted over the Internet and will not be shared with anyone but the staff of Horizon Hospice. If you would prefer, you may phone in the information to our Referral Coordinator at 509-489-4581, 8:30 - 5:00, Monday through Friday, Pacific; print out this page and fax it to us at 509-482-0717; or mail it to 123 W. Cascade Way, Suite A, Spokane, WA 99208.
Please complete the following
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Which type of service?
Hospice
Palliative Care
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Patient name:
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Patient phone (including area code):
Patient diagnosis (if known):
Your name (if you are not the patient):
Your phone (including area code):
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Your relationship to patient:
Have you told the patient we might be calling?
Yes
No
Comments/questions, other things we should know:
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