Get Thank You For Your Referral To The Emory Liver Transplant Program - Emoryhealthcare

Completing the Thank You For Your Referral To The Emory Liver Transplant Program form is crucial for ensuring the smooth evaluation of your patient. This guide will walk you through each section of the form, providing you with clear and supportive instructions for successful submission.

Follow the steps to complete the referral form effectively.

1. Click ‘Get Form’ button to access the form and open it in a suitable editor.
2. Enter the referral date in the designated field. This is important for tracking the timeline of the referral.
3. Fill in the referring physician's name. This should include their full name and credentials, ensuring accurate identification.
4. Provide the referring address, ensuring all details are complete to facilitate communication and follow-up.
5. Input the patient's diagnosis clearly in the appropriate field. Accurate details here will expedite the evaluation process.
6. Include the referring physician's phone number and fax number for any necessary future communications.
7. Complete the patient section, beginning with the patient's first and last name, followed by middle initial if applicable.
8. Provide the patient’s Social Security number and date of birth. This information is critical for identifying the patient.
9. Select the patient’s language of choice to ensure effective communication throughout the evaluation process.
10. Fill in the patient's street address, city/state, and zip code accurately.
11. Provide the patient’s age, sex, and race, as this information may assist with tailored care considerations.
12. Include the patient’s email and county for additional contact modalities.
13. Fill out the emergency contact section, including their name, relationship to the patient, and phone number.
14. Enter the patient’s employer, occupation, and employer address to complete their profile.
15. Provide insurance details, including the company name, subscriber name, policy number, and group number.
16. Utilize the checklist section to confirm that all required medical records and documentation are attached. Ensure each item is marked as 'Yes' or 'No' accordingly.
17. Complete the form with your name and contact information, clearly indicating your role in the referral process.
18. Once all fields are completed, ensure you save changes, download, print, or share the form as required.
19. Finally, fax the completed form along with all requested materials to the provided fax number.

Begin completing your documents online today to ensure a smooth referral process for your patient.