Get Ct Yale New Haven Health Required Patient Information 2014-2025

Filling out the CT Yale New Haven Health Required Patient Information form is a crucial step in ensuring you receive the appropriate care and support. This guide will provide you with clear instructions on how to complete each section of the form online, ensuring all necessary information is accurately submitted.

Follow the steps to complete the required patient information form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's full name in the designated field, followed by their medical record number and EPIC number, if available.
3. Fill out the date of birth, current address, and the best daytime phone number to reach the patient. Ensure all details are current and accurate.
4. Specify the type of diet instruction needed by writing a brief description in the provided space.
5. List any relevant medications the patient is currently taking in the appropriate section.
6. Provide pertinent clinical information such as hemoglobin A1C, lipid profile, and allergy panels by faxing the information to the designated number.
7. Select all applicable reasons for referral by checking the boxes next to the appropriate categories, and write in any additional diagnoses with their respective ICD-9 codes.
8. Complete the Physician Information section by filling in the referring physician's name, address, phone number, and fax number, as well as obtaining their signature.
9. After reviewing all information for accuracy, proceed to save any changes made to the form. You may then choose to print the form, download it, or share it as needed.

Complete the CT Yale New Haven Health Required Patient Information form online today for timely processing of your healthcare needs.