Hospice Agency Questionnaire

Insurers and accrediting bodies send this questionnaire to palliative care providers seeking approval. It covers contact details, ownership type, staffing, admission hours, permitted treatments and quality assurance practices. Reviewers can then compare providers against the same set of criteria without chasing missing paperwork.

Use this template

Date Today

Name of the hospice agency

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Primary Contact Person

Nombre

Apellido

Director or Administrator Name

Nombre

Apellido

Type of agency by services provided

Home based care Inpatient unit Residential facility Combined services

Type of agency by ownership

For profit Non-profit Government owned

Is this agency certified by Medicare?

Yes No Pending

If yes, what is the Medicare provider number?

Upload copies of the current federal and state survey reports

Max 10 MB per file

What is the most common diagnosis among your patients?

Source of referral

What are the agency's business hours?

Latest time of day admissions are accepted

Explain the agency's intake procedure

Are your nurses certified?

Yes No Partially

If yes, what percentage is certified? (%)

Does the agency provide paediatric hospice care?

Yes No

Does the agency belong to a chain or affiliation?

Yes No

If yes, what is the name of that organisation?

Does the agency allow palliative treatments such as chemotherapy or radiotherapy?

Yes No Case by case

Does the agency allow IV lines and transfusions?

Yes No Case by case

Do you admit patients who have no caregiver?

Yes No Case by case

Describe the agency's quality assurance process

Do you have case managers working directly with patients?

Yes No

Which case management model do you use? Explain below

Who or which department communicates with insurers?

Is there a formal procedure for handling complaints?

Yes No

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