Get the free LDL Apheresis Referral Form (PDF format) - Hartford Hospital! - harthosp

HARTFORD HOSPITAL LDL APHERESIS Phone: 860-545-0594 Fax: 860-545 -2882 LDL APHERESIS REFERRAL FORM: Patient Name: DOB: Phone: Contact if different from patient: REFERRING MD: REASON FOR REFERRAL LDL

How to fill out ldl apheresis referral form

How to fill out an LDL apheresis referral form:

1. Start by gathering all the necessary information. The referral form will likely require details about the patient's medical history, current medications, and any relevant lab results related to their cholesterol levels.
2. Fill in the patient's personal information accurately, including their name, contact information, and date of birth. Ensure that all the information provided is legible and correct, as mistakes or missing details could lead to delays in the referral process.
3. Provide the relevant medical history of the patient. This may include information about their diagnosis of familial hypercholesterolemia or other conditions that warrant LDL apheresis treatment. Include any relevant documentation, test results, or previous treatments that may support the need for referral.
4. Indicate the medication and treatment history of the patient. Include the names and dosages of any medications they are currently taking to manage their cholesterol levels. Be sure to provide dates and any changes made in their medication regimen.
5. Include any additional information or details that might be beneficial for the referring healthcare professional. This may include the patient's preferences, specific concerns, or any previous experiences related to LDL apheresis or similar treatments.

Who needs an LDL apheresis referral form?

1. Patients with severe familial hypercholesterolemia: LDL apheresis is often recommended for individuals who have familial hypercholesterolemia and are unable to achieve satisfactory cholesterol levels with other treatment options such as lifestyle modifications and medication.
2. Patients with a history of cardiovascular disease: Individuals who have experienced cardiovascular events, such as heart attacks or strokes, and have persistently high LDL cholesterol levels may require LDL apheresis to lower their cholesterol levels and reduce the risk of further complications.
3. Patients with extremely high LDL cholesterol levels: LDL apheresis may be considered for individuals who have exceptionally high LDL cholesterol levels that are resistant to conventional treatments. This includes individuals with genetically determined abnormalities in their cholesterol metabolism or those who have not responded adequately to medication or lifestyle changes.

It's important to note that the decision to refer a patient for LDL apheresis will depend on the healthcare professional's clinical judgment and the local guidelines or protocols in place. Referral criteria may differ between healthcare facilities and regions.

For pdfFiller’s FAQs

What is ldl apheresis referral form?

The LDL apheresis referral form is a document used to refer patients for LDL apheresis, a procedure that removes LDL cholesterol from the blood.

Who is required to file ldl apheresis referral form?

Healthcare providers and physicians who are referring patients for LDL apheresis are required to file the LDL apheresis referral form.

How to fill out ldl apheresis referral form?

To fill out the LDL apheresis referral form, you need to provide patient information, medical history, reason for referral, and any necessary documentation.

What is the purpose of ldl apheresis referral form?

The purpose of the LDL apheresis referral form is to facilitate the referral process for patients who require LDL apheresis treatment.

What information must be reported on ldl apheresis referral form?

The LDL apheresis referral form typically requires information such as patient demographics, referring physician details, medical history, diagnosis, and reason for referral.

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