Qualification to palliative care is more demanding when the number of referred patients exceeds the admission capabilities of an institution. In such cases the selection of urgent admission needs (when management aside from hospice care is problematic) may be essential. For this purpose the palliative care referral form (PCRF) containing additional information on disease stage, patient’s performance, symptoms of suffering, previously applied therapies and social concerns was developed and prospectively analyzed. The aim of the study was to assess the qualification to palliative care accuracy in a group of 41 patients based on the PCRF. At first the qualification was based solely on the PCRF data, then (on the second day after admission) a structured interview with an attending physician was conducted. Pairs of these data were compared and analyzed. All palliative referrals were legitimized on admission. Among 26 patients triaged as “urgent”, 19 were such on admission, within 15 staged as “stable” 13 were confirmed later. Also, the disease stage and patients’ performance were usually confirmed on admission. The high PCRF ability to predict the need of urgent implementation of palliative care was observed. (positive predictive value of 73,1%, sensitivity 90,5%) The PCFR which is legitimate, provides the essential information for preliminary qualification to palliative care and accurate assessment of its urgent indications. It may simplify and accelerate the process thus lowering costs. Wider practical application of the PCRF in the hospice care is proposed.