Outpatient Palliative Care Referral Form

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Outpatient Palliative Care
Referral Form
Referral Guidelines and Process
1. Patient is a member of CareOregon Advantage (Plus or Star) or OHP Plus HSO/CareOregon living in
Clackamas, Multnomah or Washington Counties and has a life limiting medical condition.
2. If uncertain of eligibility or you have palliative care questions, please contact Kristi Youngs, RN at
503-416-5906 or via secure email to:
3. Fax referral form to CareOregon Attn: Kristi Youngs, Palliative Care Coordinator at 503-416-3724
a. Referrals will be coordinated with Adventist Health Options or Care Partners for palliative care
services.
Member Information
Member Name: _______________________________________DOB: ____/____/____
ID#: _____________
Phone Number: _________________or_________________ County: Clackamas / Multnomah / Washington
Member Address: __________________________________________________________________________
Referral Information
Reason for Referral: ________________________________________________________________________
__________________________________________________________________________________________
Have you personally discussed this referral with the member or significant other?
Yes
No
Primary Diagnosis: ___________________________________________________ ICD-9 code: __________
Is the member aware of their diagnosis and prognosis?
Yes
No
Co-existing disease or complications: _________________________________________________________
Psychosocial concerns: _____________________________________________________________________
PCP Name: ______________________ Phone #______________ PCP is aware of the referral?
Yes
No
Specialist:_______________________ Phone #______________Specialist is aware of referral?
Yes
No
Referral Contact Information
Name of Person Completing Form: ____________________________________   
 
Date: _____/______/_______
 
Phone #: __________________________  Best time to contact you:___________________________________ 
 
Referral From:    Provider     Care Management     Health Integrated     Health Resilience Program    C‐TraIn 
 Other:_____________________________ 
When possible include the following information with referral:
Recent clinician chart/case notes
Admission H&P/Discharge summary from recent hospitalization
Current Medication List
Current Advanced Directive/POLST

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