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    Admission Procedure Checklist

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    List of documents to complete for your Admission to Coming Home Hospice

    Confirm that patient has met all eligibility criteria.

    The following information must be complete and included in the application in order to place the patient on the waiting list and consider him/her for admission:
    • Formal referral with a doctor’s order to start care. Please call the Coming Home Hospice Intake Coordinator at 415-861-1110.

    • Admission Application; H & P with current medication list; related consults; related Nursing Progress Notes; behavior issues of concern; and any specific social concerns.

    • Written confirmation of the name, address and phone number of an immediate family member or durable power of attorney for health care, and/or for finances, whenever possible; including a copy of the forms appointing the power(s) of attorney.

    • Adjusted Net Income Worksheet.

    • Responsibility for Finances. If the patient can not afford the Room & Board fee, please contact the Social Worker at Coming Home Hospice.

    • Written confirmation of a chest x-ray taken within 3 months of admission to CHH that shows no evidence of pulmonary tuberculosis. (A PPD may be acceptable for persons with intact immune systems.) If the person has pulmonary TB, written confirmation of at least 2 weeks of treatment and three consecutive negative AFB smears is required.

    • Admission Agreement signed by the patient, a close family member or a Durable Power of Attorney.

    • Medical guidelines for determining prognosis in selected non-cancer diseases.
    Mail or fax application to:

    CHH Intake Coordinator
    Coming Home Hospice
    115 Diamond Street
    San Francisco, CA 94114
    FAX to 415-861-5763