Call Now 24/7/365

800.497.9559

Donate

Services
Services
About
Donors
Volunteer
Resources
Careers
Contact
800.497.9559
Donate

SMILE

SMILE Request and Information

FOR STAFF TO COMPLETE

For questions or form submissions, email Smile@HarborHospiceMI.org or contact your supervisor.

Patient name

First Last

Description of request

Special instructions or requests (e.g., specific business, photographer, or other details)

Approximate cost, if known

Level and urgency of request

Level 1

Level 2

Level 3

Hospice team

HHA

Who is requesting

Patient

Representative

Person to be contacted with questions/additional information (family/PCG)

Name

First Last

Phone

Relationship

If the contact is someone other than the patient, does the patient know and agree?

If the request involves travel:

Traveling address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Traveling phone

Who will travel with the patient?

Anticipated travel dates (if unknown due to the nature of the request, leave blank)

Needs to be ordered (DME, oxygen type and liter flow, visits, CADD pumps, special medication needs)

Other information

FOR COORDINATOR TO COMPLETE

SMILE coordinator received date

MM slash DD slash YYYY

SMILE level

SMILE coordinator reviewed date

MM slash DD slash YYYY

Status

Approved

Denied

Moved to next level

Document recipient and date

Actions taken

Final status

Approved

Denied

For more information, call 24 hours a day.

Call Harbor Hospice

Trusted by West Michigan patients and families for more than 40 years to provide the best palliative care, hospice care, and grief support, so no one has to face life’s hardest moments alone.

Legal

Privacy Policy
Terms of Use
Site Map

Social

Facebook Linkedin Youtube Instagram

Contact

Keep me up to date!

Hospice Care

Palliative Care

Grief Support

Paying for Services