Get E2c2 Request Form - Brighamandwomens

The E2C2 Request Form is essential for facilitating expedited evaluations and cardiac catheterizations at Brigham and Women's Hospital. This guide provides clear instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the form effectively

1. Press the ‘Get Form’ button to access the E2C2 Request Form and open it in your preferred online editor.
2. Begin by filling out the referring clinician's information. Enter your full name, contact phone number, email address, and fax number in the designated fields.
3. Next, proceed to the patient information section. Provide the patient's full name, gender (select M or F), and date of birth in the specified formats. Additionally, include the patient's contact phone number.
4. Indicate whether the patient has previously visited Brigham and Women's Hospital by marking 'Y' for yes or 'N' for no.
5. In the critical history section, mark 'Y' or 'N' for each relevant medical history item, including history of myocardial infarction, CABG, coronary stent, peripheral vascular surgery, contrast allergy, use, known allergies, premenopausal status, and renal insufficiency. Provide details when necessary.
6. Complete the information required section by checking the availability of the brief history and physical, laboratory results, EKG, and stress test results, ensuring these documents are from within the last 30 days.
7. Select the type of expedited evaluation requested by checking the appropriate box: evaluation on the same day as the planned procedure or priority outpatient clinic.
8. After completing all sections, ensure that all information is accurate. Save changes, download the form, or print it as needed.
9. Finally, fax the completed form and any requested information to the designated contacts provided within the form.

Complete your E2C2 Request Form online now to ensure a smooth submission process.