Am I Eligible?

Hospice of South Texas provides physical, spiritual and emotional care and support to patients and families during end stage illness. If you would like to learn more about Hospice of South Texas and how we can help, please complete and submit the following form online or use the printable form and mail in your response. One of our team members will contact you soon. You may also contact us directly at 1.800.874.6908.

Please check the following statements as they apply to you or your loved one to see if Hospice care is appropriate.

I have started feeling more tired and weak

I experience shortness of breath, even when resting

I spend most of the day in bed or in a chair

I have noticed an increased weight loss in the past six months

I make frequent phone calls to my physician

I take medications to lessen physical pain

I have fallen several times in the past six months

I have made frequent trips to the emergency room in the past six months

I need help from others with important daily activities
(Bathing, Dressing, Eating, Cooking, Walking, Getting out of bed)

My doctor has told me my life expectancy is limited

You or your loved one may be eligible for Hospice care if you checked 4 or more statements. However, even when criteria is not met, clinical opinion guides eligibility.

Name:
Patient's Name:
Relation to Patient:
Patient's Zip Code:
Your Phone Number:
Your Email Address:
Preferred Method of Contact:	By Phone By Email
Best Time to Cotact:	Early Morning Mid Morning Noon Early Afternoon Late Afternoon Early Evening
How did you learn about Hospice of South Texas:	Physician Radio Newspaper Other (Include in comments)	Friend Television Nursing Home	Billboard Website Hospital
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