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Get Duke Liver Transplant Referral Form
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How to fill out the Duke Liver Transplant Referral Form online
The Duke Liver Transplant Referral Form is essential for facilitating the evaluation and care of patients with liver disease. This guide provides clear, step-by-step instructions for successfully completing the form online.
Follow the steps to complete the Duke Liver Transplant Referral Form efficiently.
- Press the ‘Get Form’ button to obtain the form and open it in your chosen editor.
- Begin with the Patient Demographic Information section. Fill in the date, patient’s full name, and indicate if the patient is a veteran by selecting 'Y' for yes or 'N' for no. Provide the patient's address, city, state, zip code, social security number, date of birth, gender, and contact numbers (home, work, cell). Do not forget to include the patient's email address and emergency contact information.
- In the Referring Physician Information section, complete the physician's name, practice name, address, city, state, zip code, office phone, fax, and email address. Identify who completed the form by entering their name.
- Next, you will need to provide insurance information. Indicate if the patient has Medicare, Medicaid, or private insurance by checking the appropriate box. Attach copies of both sides of the insurance cards as required. Include the policyholder’s name, date of birth, policy number, insurance phone, and group number.
- In the Patient General Clinical Information section, specify whether the patient has ever been seen at Duke University Hospital by selecting 'Yes' or 'No.' If applicable, enter the date of the last visit and the Duke history number. Also, provide the patient's height, weight, and smoking cessation date if relevant.
- Finally, review all the completed sections for accuracy and completeness. Once satisfied with the information provided, you can save your changes, download, print, or share the filled form as necessary.
Take action now and complete the Duke Liver Transplant Referral Form online for a timely evaluation.
Nationally, the waiting list for a liver transplant varies and can consist of many patients across the country. Factors like donor organ availability largely influence how long individuals may wait. To better understand your position and begin the process, it is advisable to fill out the Duke Liver Transplant Referral Form as soon as possible.
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