Primary Care to Palliative Care Referral Form

Primary Care to Palliative Care Referral Form: Compassionate Transitions Made Simple

When patients face serious illness, ensuring seamless communication between primary care and palliative care teams can make all the difference in providing comfort-focused, patient-centered care. This Primary Care to Palliative Care Referral Form template helps primary care physicians, nurse practitioners, and care coordinators streamline the referral process while capturing the essential clinical and psychosocial information palliative care specialists need to provide comprehensive support.

Why This Form Matters for Healthcare Providers

Palliative care referrals require more than basic demographic information—they need a holistic picture of the patient's diagnosis, symptom burden, goals of care, and advance planning status. This template addresses the unique needs of:

• Primary care physicians seeking to connect patients with palliative care services early in their illness trajectory
• Oncologists and specialists who recognize when symptom management and quality of life support are needed
• Hospital case managers coordinating post-discharge palliative care
• Hospice agencies receiving referrals for evaluation
• Palliative care teams who need comprehensive intake information to provide person-centered care

By digitizing this critical handoff, you eliminate illegible faxes, incomplete referrals, and communication delays that can prevent patients from receiving timely symptom relief and advance care planning support.

What Makes This Template Effective

This form goes beyond basic referral information to capture:

• Comprehensive diagnosis information including primary and secondary diagnoses, disease stage, and prognosis
• Detailed symptom burden assessment covering pain, dyspnea, nausea, fatigue, anxiety, depression, and other common symptoms
• Advance directive documentation to understand existing care preferences and planning needs
• Quality of life goals that help palliative teams align care with what matters most to patients
• Functional status and caregiver information for holistic care planning
• Urgency indicators to help palliative teams prioritize consultations appropriately

The conditional logic built into this template ensures referring providers only see relevant follow-up questions based on their responses, making the form faster to complete while still capturing comprehensive information.

How Paperform Transforms Palliative Care Referrals

Traditional paper-based referrals often go missing, get delayed in fax queues, or arrive with crucial information left blank. This Paperform template solves those problems:

Faster referral processing: Digital submissions arrive instantly in your palliative care team's workflow, eliminating mail and fax delays that can postpone critical symptom management.

Complete information capture: Required fields and conditional logic ensure every referral contains the clinical details palliative teams need, reducing back-and-forth calls for missing information.

Improved care coordination: Integrate submissions with your EHR, care coordination platform, or case management system using Paperform's native integrations or Stepper workflows to automatically create patient records and notify the appropriate team members.

Better patient outcomes: When palliative care teams receive comprehensive referral information upfront, they can prepare more effectively for initial consultations and begin addressing symptom burden and care planning immediately.

Secure HIPAA-considerations: While Paperform is not HIPAA-compliant, you can use this template for administrative coordination while transmitting PHI through compliant channels, or implement it within your organization's secure infrastructure.

Ideal for Multiple Healthcare Settings

This template adapts to various palliative care referral scenarios:

• Primary care offices referring patients with advanced cancer, heart failure, COPD, or neurodegenerative diseases
• Hospital-based palliative care programs receiving inpatient and outpatient referrals
• Oncology practices integrating concurrent palliative care for symptom management
• Home health agencies coordinating palliative services
• Hospice organizations receiving referrals for eligibility evaluation

Automate Your Referral Workflow with Stepper

Once a referral is submitted, Stepper—Paperform's AI-native workflow automation platform—can help you coordinate the next steps:

• Automatically send referral notifications to the appropriate palliative care team member based on geographic location or specialty
• Create tasks in your care coordination system for intake coordinators to contact patients
• Update your patient management database with new referral information
• Send confirmation messages to referring providers acknowledging receipt
• Route urgent referrals to on-call teams for same-day or next-day consultations
• Generate intake appointment scheduling links for patients and caregivers

Designed for Compassionate Care

The language and structure of this form template reflect the sensitive nature of palliative care referrals. Questions are framed with empathy, and the form guides providers through a logical progression from clinical information to psychosocial and spiritual concerns—mirroring the holistic approach of palliative care itself.

Whether you're a primary care practice looking to improve your serious illness communication and referral processes, a hospital palliative care program seeking to standardize intake, or a hospice agency wanting complete information from referring providers, this template provides the foundation for effective, compassionate care transitions.

Get Started in Minutes

This template is ready to use immediately—just customize the recipient email addresses, adjust any clinical terminology to match your organization's preferences, and embed it on your website or share it directly with referring providers. With Paperform's intuitive editor, you can add your organization's branding, modify symptom scales, or include additional assessment tools without any coding required.

Trusted by healthcare providers worldwide, Paperform offers SOC 2 Type II compliance, secure data handling, and the flexibility to integrate with your existing care coordination tools. Start facilitating better palliative care referrals today.