Get Uk Healthcare Heart Transplant And Ventricular Assist Device Consultation Form

Filling out the UK HealthCare Heart Transplant And Ventricular Assist Device Consultation Form online is a crucial step in referring a patient to the specialized heart transplant program. This guide will provide a clear, step-by-step process to ensure you correctly complete the form and submit all necessary information.

Follow the steps to effectively complete the consultation form.

1. Press the ‘Get Form’ button to open the UK HealthCare Heart Transplant And Ventricular Assist Device Consultation Form in your document editor.
2. Begin by filling out the patient information section. Provide the patient's last name, first name, middle initial, and date of birth formatted as month/day/year. Ensure accuracy in this section to avoid confusion later.
3. Complete the mailing address field by entering the patient’s full address, including city, state, and zip code. This information is vital for any follow-up correspondence.
4. Enter the patient’s Social Security number accurately. This helps in identifying the patient's records in the healthcare system.
5. Choose the patient's sex by selecting either 'Male' or 'Female'. If applicable, provide the maiden name of the patient.
6. Fill in the patient's phone number and indicate whether an interpreter is needed by selecting 'Y' for yes or 'N' for no.
7. Select the appropriate clinic location for the consultation: either Lexington or Louisville.
8. In the referring physician information section, input the physician's name, contact name, and their phone number, ensuring all details are current.
9. Provide the physician NPI number and email address. This information is essential for communication between the referring physician and the transplant center.
10. Include the physician’s address, city, state, zip code, and county to complete this section.
11. Lastly, make sure to attach all necessary documents requested at the beginning of the form, such as recent laboratory results, patient demographic sheet, previous cardiac testing, and insurance cards.
12. Once all sections are completed and verified, save the form changes. You may then download, print, or share the form as needed to complete the referral process.

Take the next step in ensuring patient care: complete and submit the UK HealthCare Heart Transplant And Ventricular Assist Device Consultation Form online today.