Get Cystic Fibrosis Lung Transplanttemplate Referral Form 2019
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How to fill out the Cystic Fibrosis Lung Transplanttemplate Referral Form online
Filling out the Cystic Fibrosis Lung Transplanttemplate Referral Form is a crucial step for initiating the referral process to a lung transplant center. This guide will assist you in completing the form accurately and efficiently, ensuring that you provide all necessary information.
Follow the steps to complete the form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin with the patient demographic information section. Provide the patient's full name, gender, veteran status, marital status, address, city, state, zip code, social security number, date of birth, race, and contact information including home, work, and cell phone numbers, as well as email.
- Fill in the emergency contact information, including the name and phone number. Indicate the patient's language, employment status, and any special needs. If applicable, specify if an interpreter is required.
- Complete the physician information section. Enter the name and contact details of the referring physician, including the CF center, practice/group name, address, phone, fax, and email. Also, provide the details for the primary care physician.
- Provide the primary insurance information. Include the company name, policy ID, policyholder’s name and date of birth, insurance phone number, and any required referral or pre-certification numbers. Make sure to mention the employer's name if using private insurance.
- If applicable, fill out the secondary insurance information using the same fields as in the primary insurance section.
- In the required medical information section, indicate the primary diagnosis, CFTR genotype, and reason for the referral. Include height, weight, and BMI, as well as nutritional status and management details.
- Detail any other relevant medical history, such as kidney or liver disease, oxygen requirements, smoking status, and frequency of exacerbations in the past 12 months.
- Attach the necessary medical records as specified, including pulmonary clinic notes, hospital discharge summaries, pulmonary function tests, lab results, and immunization records.
- Review all completed sections, ensuring accuracy, before saving your changes. You may then download, print, or share the completed form as needed.
Start completing the Cystic Fibrosis Lung Transplanttemplate Referral Form online today.
FEV1, or forced expiratory volume in one second, is a critical measurement in evaluating lung function for cystic fibrosis patients. Typically, an FEV1 value below 30% indicates that the patient is experiencing life-threatening lung failure and may be a candidate for a lung transplant. Monitoring FEV1 levels helps determine when to refer patients using the Cystic Fibrosis Lung Transplanttemplate Referral Form.
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