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Heart Transplant Assessment Referral Form STRICTLY CONFIDENTIALAttention to: Heart Transplant Physician Dr: cc The Transplant Assessment Nurse Heart & Lung Transplant Unit St. Vincent's Hospital 390
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How to fill out heart transplant assessment referral
How to fill out heart transplant assessment referral
01
Collect all relevant medical records and test results to provide a comprehensive assessment.
02
Contact the appropriate medical facility or organization that handles heart transplant assessment referrals.
03
Fill out the referral form with accurate and detailed information about the patient's medical condition, history, and any relevant factors.
04
Include the patient's demographic information, such as name, date of birth, address, and contact details.
05
Provide information about the patient's primary care physician and any specialists involved in their treatment.
06
Provide a thorough explanation of the patient's heart disease diagnosis, including any previous heart surgeries or procedures.
07
Include information about the patient's current symptoms, medications, and treatments.
08
Describe the patient's overall health status, including any comorbidities or underlying health conditions.
09
Attach supporting documents, such as imaging reports, lab results, and electrocardiograms.
10
Submit the completed referral form and supporting documents to the designated medical facility or organization either through mail, fax, or online submission.
Who needs heart transplant assessment referral?
01
Patients who are diagnosed with advanced heart failure and have exhausted all other available treatment options may need a heart transplant assessment referral.
02
Individuals with severe heart disease or congenital heart defects that significantly affect heart function may also require a heart transplant assessment referral.
03
Patients who have been deemed eligible for a heart transplant based on preliminary evaluations or medical recommendations.
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What is heart transplant assessment referral?
Heart transplant assessment referral is a process where a patient is referred for evaluation to determine if they are a candidate for a heart transplant.
Who is required to file heart transplant assessment referral?
The patient's cardiologist or primary care physician is required to file the heart transplant assessment referral.
How to fill out heart transplant assessment referral?
The referring physician must complete the referral form with the patient's medical history, current condition, and any relevant test results.
What is the purpose of heart transplant assessment referral?
The purpose of the heart transplant assessment referral is to assess the patient's eligibility for a heart transplant and to initiate the evaluation process.
What information must be reported on heart transplant assessment referral?
The referral must include the patient's medical records, diagnostic tests, current medications, and any relevant imaging studies.
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