NORTH
WEST
KANSAS
Area Agency on Aging, Inc.
C.A.R.E.
Program
DATE:
_______________________________
_____Number
of Pages (including cover sheet)
TO:
Tammy
Gerhardt, CARE Coordinator
FROM:
________________________________
Medical Condition Checklist
q
Physician’s Statement that client is terminally ill with a life
expectancy of 6 months or less if the terminal illness runs its normal course.
This is a separate document.
q
Name of Hospice
Please check one
o
Hays
Medical
Center
– FAX 785-623-5465
o
Southwind Hospice – FAX 785-483-4171
o
Hospice Services Inc. – FAX 785-543-5688
o
Other: Name:
___________________________ Fax:
______________
q
Hospice Contact Person
_______________________________________
q
Name of Nursing Facility
_______________________________________
q
Address of Nursing Facility
_______________________________________
_______________________________________
Additional Comments:
If you have any questions,please contact Tammy G at (785) 625-2037
CONFIDENTIALITY NOTICE:
The documents accompanying this FAX transmission contain confidential
information belonging to the sender which is legally privileged.
The information in intended only for the use of the individual or entity
named above. If you are not the
intended recipient, you are hereby notified that any disclosure, copying,
distribution or taking of any action in reliance on the contents of the Faxed
Information is strictly prohibited. If
you have received this FAX in error, please immediately notify us by telephone
to arrange for return of the original documents to us.
Thank you for your cooperation.
510 W 29th Street
, Suite B
Hays,
Kansas
, 67601
toll free 1-800-432-7422