How To Get Help Blessing Palliative Care is committed to providing care and support for patients and families during one of life’s most difficult times. We want to make obtaining the needed information, care, and services easy. Please complete the online form for information and a Palliative Care representative will contact you the next working day Monday - Friday. To contact us, call 217-223-8400, ext. 5533 anytime between 8 am - 4:30 pm, Monday-Friday. INFORMATION ABOUT YOU Name First Last Email Address Phone Number Patient Referral Information If making a referral for services, please complete the remaining information below. Patient Name First Last Patient Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code County (If Known) Patient's Physician Your Relationship To Patient Patient's Phone Number Additional Information CAPTCHA What code is in the image? Enter the characters shown in the image. Submit Leave this field blank
