Get Tx Methodist West Houston Hospital Cardiac Rehabilitation Program Referral Form

Filling out the TX Methodist West Houston Hospital Cardiac Rehabilitation Program Referral Form online is a crucial step in initiating a patient's cardiac rehabilitation journey. This guide will provide you with clear and supportive instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the referral form.

1. Click the ‘Get Form’ button to access the referral form and open it in the designated form editor.
2. Begin by entering the patient's name in the appropriate fields, including last name, first name, and middle initial.
3. Fill in the home phone number and the day phone number for the patient. Ensure that you use the correct area codes.
4. Provide the patient's date of birth in the specified format to ensure accurate record-keeping.
5. Indicate the patient's primary insurance provider by writing the name of the insurance company in the designated field.
6. Select the correct referral option by choosing between an initial prescription for cardiac rehabilitation or a renewal for additional sessions. Circle the relevant option accordingly.
7. If renewing the prescription, ensure to include the medical justification for the renewal in the provided field.
8. Attach relevant information that supports patient care, including the hospital discharge summary, EKG, lipid profile, recent exercise test, catheterization report, and echocardiogram report.
9. Indicate applicable diagnoses related to the patient's condition by marking the appropriate boxes for each condition.
10. List the current medications the patient is taking in the provided space, ensuring clarity and completeness.
11. Add any special instructions for the attending staff in the designated area to communicate any specific patient needs.
12. Sign the form by entering the physician's name and affixing the physician's signature to validate the referral.
13. Provide the physician's phone number, fax number, address, city, state, and zip code in the specified fields.
14. Once all sections are complete, review the form for accuracy. You can then save changes, download a copy, print it for your records, or share it as needed.

Complete your referral form online today and help initiate the cardiac rehabilitation process for your patient.