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REFERRAL FORM: Pulmonary Rehabilitation Program * Please see inclusion/ exclusion criteria on reverse to ensure referral is appropriate* Date of referral: ___ Advance Care Planning: Comfort care only

How to fill out referral form and criteria

How to fill out referral form and criteria

1. Obtain the referral form from the appropriate source (e.g. doctor's office, hospital, clinic)
2. Fill out the patient's personal information accurately, including name, date of birth, address, contact information
3. Provide details about the reason for the referral, including any relevant medical history or conditions
4. Include any supporting documents or test results that may be required
5. Submit the completed referral form to the designated recipient as specified on the form

Who needs referral form and criteria?

1. Patients who require specialized medical treatment or services beyond the capabilities of their primary care provider
2. Healthcare professionals who are referring a patient to a specialist or other healthcare provider for further evaluation or treatment

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What is referral form and criteria?

The referral form and criteria is a document used to refer individuals to a specific program or service based on certain requirements or qualifications.

Who is required to file referral form and criteria?

Individuals or organizations responsible for making referrals are required to file referral form and criteria.

How to fill out referral form and criteria?

The referral form and criteria can be filled out by providing the necessary information requested on the form, such as personal details, reason for referral, and any specific criteria that need to be met.

What is the purpose of referral form and criteria?

The purpose of the referral form and criteria is to ensure that individuals are referred to the appropriate program or service that meets their needs and qualifications.

What information must be reported on referral form and criteria?

The referral form and criteria may require information such as personal details, reason for referral, specific criteria for eligibility, and any relevant documentation.