Get Or Legacy Health Anticoagulation Clinic Referral Form 2011-2025

Filling out the OR Legacy Health Anticoagulation Clinic Referral Form online is an essential process for coordinating anticoagulation therapy for patients. This guide will provide you with step-by-step guidance to help you accurately complete the form and ensure all necessary information is submitted effectively.

Follow the steps to successfully complete the referral form

1. Press the ‘Get Form’ button to obtain the form and open it in the desired online editor.
2. Begin by entering the patient's name, date of birth, and medical record or social security number in the designated fields.
3. Indicate if the patient is currently an inpatient by filling in their room number and expected discharge date. If they are an outpatient, provide their phone number and an alternate contact information.
4. Choose the appropriate anticoagulation protocol or order from the options provided, ensuring to specify the dose and frequency for any injectable anticoagulants if applicable.
5. List the indications for anticoagulation by checking the relevant boxes such as Atrial Fibrillation, Stroke, or Deep Vein Thrombosis, and provide any necessary additional information.
6. If there are other medical problems not already documented, please specify them in the space provided.
7. Select the goal INR range by checking the corresponding box that aligns with the patient's condition.
8. Indicate the duration of anticoagulation by checking the appropriate option and providing any specific details if required.
9. Fill in the name of the physician responsible for interim management and detail the interim management plan or current dose.
10. Authorize the Legacy Anticoagulation Clinics to provide services by signing and dating the authorization section, and print your name along with contact information.
11. Identify any different provider who will follow the patient for anticoagulant therapy if applicable and ensure that the ordering provider has Legacy Medical Staff privileges.
12. Attach any necessary records such as health history or medication lists, ensuring they are comprehensive and complete.
13. Once all information is filled out, save the changes, and proceed to download, print, or share the form as needed.

Start completing the OR Legacy Health Anticoagulation Clinic Referral Form online now for efficient patient care.