Advanced Heart Failure Referral

Thank you for your interest in the UAB Advanced Heart Failure and Pulmonary Vascular Disease Program.

For your convenience, we offer two easy methods to refer your patient. Click here to download a printable form, which may be completed and faxed back to us, or simply complete and submit the electronic form below and we will contact your office.
Your completion of all the fields below will ensure that there are no unnecessary delays in the evaluation of your patient.

In addition to completing the referral form, please mail or fax the bulleted information below to:
UAB Advanced Heart Failure
1900 University Boulevard
THT 311
Birmingham, AL 35294
Phone: (205) 934-3438
Fax: (205) 975-9320

Patient Demographics
Copy of front/back of insurance cards (if available)
Most recent cardiac/pulmonary testing reports (echocardiogram, left and/or right heart catheterization, pulmonary function testing)
For testing that has associated images, please send a copy of the most recent testing via Vital Engine, by mail or with the patient. (Receipt of this imaging will not delay scheduling.)
Most recent clinic note

Reason for Referral(Required)

Patient Name(Required)

First Last

Date of Birth(Required)

SSN

Patient Phone Number(Required)

Referring MD(Required)

First Last

NPI

Referring MD Office Number(Required)

Referring MD Fax Number(Required)

Additional Remarks