Get the free Supportive Care Referral Form

This form facilitates referrals to the NYGH Supportive Care Clinic for managing advanced heart failure or lung disease symptoms, ensuring effective care coordination.

How to fill out supportive care referral form

How to fill out supportive care referral form

1. Begin by gathering patient information, including full name, date of birth, and contact details.
2. Fill in the medical history section, detailing any relevant health conditions and treatments.
3. Provide information on current medications, including dosages and frequency.
4. Indicate the reason for the referral, specifying any particular needs or symptoms.
5. Include details on the patient's psychosocial background, such as support systems and living conditions.
6. Attach any relevant medical records or assessments that support the referral.
7. Review the form for completeness and accuracy before submission.
8. Submit the form to the designated supportive care team or department.

Who needs supportive care referral form?

1. Patients undergoing complex medical treatments, such as cancer therapy.
2. Individuals experiencing chronic pain or debilitating symptoms.
3. Patients with emotional or psychological distress related to their illness.
4. People with limited social support networks or resources.
5. Those requiring assistance with daily living activities due to health conditions.

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What is supportive care referral form?

The supportive care referral form is a document used to request and document referrals for supportive care services for patients, ensuring they receive appropriate assistance for their physical, emotional, and social needs.

Who is required to file supportive care referral form?

Healthcare providers, including physicians and specialized care teams, are typically required to file the supportive care referral form on behalf of their patients who need additional support.

How to fill out supportive care referral form?

To fill out the supportive care referral form, providers must input patient demographics, specific supportive care needs, medical history, and any relevant notes or recommendations for care.

What is the purpose of supportive care referral form?

The purpose of the supportive care referral form is to facilitate access to supportive services, enhance patient care coordination, and ensure that patients receive comprehensive support throughout their treatment process.

What information must be reported on supportive care referral form?

The supportive care referral form must include patient identification details, the referring provider's information, specific supportive care recommendations, and any pertinent medical information relevant to the care being requested.