Get the free Anticoagulation Clinic Referral Form - Prisma Health

YOU HAVE REQUESTED AN APPOINTMENT FOR: Today's Date: ___ Patients Phone Number: ___ Patient Name: DOB: REFERRING PROVIDER: PCP:REASON FOR VISIT: (DAC will provide authorization services): Infusion/Injection

How to fill out anticoagulation clinic referral form

How to fill out anticoagulation clinic referral form

1. Obtain the anticoagulation clinic referral form from the healthcare provider or clinic.
2. Fill out patient demographic information including name, date of birth, address, and contact information.
3. Provide details about the reason for referral to the anticoagulation clinic, such as diagnosis, medications, and medical history.
4. Indicate any known allergies or contraindications to anticoagulation therapy.
5. Include any relevant lab test results or imaging studies that support the need for anticoagulation therapy.
6. Obtain necessary signatures from the healthcare provider and patient before submitting the referral form.

Who needs anticoagulation clinic referral form?

1. Patients who require anticoagulation therapy to manage conditions such as atrial fibrillation, deep vein thrombosis, pulmonary embolism, or mechanical heart valves.
2. Patients who have recently experienced a stroke or heart attack and are at high risk for blood clots.

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What is anticoagulation clinic referral form?

The anticoagulation clinic referral form is a document used to refer patients to an anticoagulation clinic for management of their anticoagulation therapy.

Who is required to file anticoagulation clinic referral form?

Healthcare providers who are managing patients that require anticoagulation therapy are required to file the anticoagulation clinic referral form.

How to fill out anticoagulation clinic referral form?

To fill out the anticoagulation clinic referral form, provide patient information, relevant medical history, current medications, specific concerns regarding anticoagulation therapy, and the referring provider's details.

What is the purpose of anticoagulation clinic referral form?

The purpose of the anticoagulation clinic referral form is to ensure proper management and monitoring of patients on anticoagulants, facilitating safe and effective treatment.

What information must be reported on anticoagulation clinic referral form?

The information that must be reported includes patient demographics, diagnosis, indication for anticoagulation, current medications, allergy history, and any relevant laboratory results.