Refer a Patient to Hospice | Northeast Texas

Thank you for referring your hospice-eligible patient to Cypress Basin Hospice. Complete the form below to submit your secure referral.

If you are a clinician who prefers to speak to us in person, call 903-577-1510 to make a referral over the phone. You may also submit pertinent medical information to our intake fax at 903-577-9377 (eg: face sheet and demographics, history and physical information).

"*" indicates required fields

Your Name:*

First Last

Phone:*

Email:*

Your relationship to patient:

If referring from a facility or physician office name of facility/office:

Patient Name:*

First Last

Location of Patient:

(home address or facility name)

Patient Contact Number:*

Caregiver Phone:*

Primary Caregiver:*

First Last

Make a Referral