{"id":346,"date":"2023-01-19T18:49:23","date_gmt":"2023-01-19T18:49:23","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=346"},"modified":"2023-01-19T18:49:23","modified_gmt":"2023-01-19T18:49:23","slug":"advanced-heart-failure-referral","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/advanced-heart-failure-referral\/","title":{"rendered":"Advanced Heart Failure Referral"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_85' ><div id='gf_85' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_85' id='gform_85'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/346#gf_85' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_85' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_85_13\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>Thank you for your interest in the UAB Advanced Heart Failure and Pulmonary Vascular Disease Program.<\/br>\n<\/br>\nFor your convenience, we offer two easy methods to refer your patient. <a href=\"https:\/\/wpvip.uabmedicine.org\/uabmedicine\/wp-content\/uploads\/sites\/3\/2023\/02\/AHF-Referral-Form.pdf\" target=\"_blank\">Click here<\/a> 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.<\/br>\n\nYour completion of all the fields below will ensure that there are no unnecessary delays in the evaluation of your patient.<\/br>\n<\/br>\nIn addition to completing the referral form, please mail or fax the bulleted information below to:<\/br>\n<strong>UAB Advanced Heart Failure<\/br>\n1900 University Boulevard<\/br>\nTHT 311<\/br>\nBirmingham, AL 35294<\/br>\nPhone: (205) 934-3438<\/br> \nFax: (205) 975-9320<\/strong><\/br>\n<ul>\n<li>Patient Demographics<\/li>\n<li>Copy of front\/back of insurance cards (if available)<\/li>\n<li>Most recent cardiac\/pulmonary testing reports (echocardiogram, left and\/or right heart\ncatheterization, pulmonary function testing)<\/li>\n<li>For testing that has associated images, please send a copy of the most recent testing via Vital\nEngine, by mail or with the patient. (Receipt of this imaging will not delay scheduling.)<\/li>\n<li>Most recent clinic note<\/li>\n<\/ul><\/p><\/div><div id=\"field_85_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_85_2' >Reason for Referral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_85_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_85_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_85_3'>\n                            \n                            <span id='input_85_3_3_container' class='name_first' >\n                                                    <input type='text' name='input_3.3' id='input_85_3_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_85_3_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_85_3_6_container' class='name_last' >\n                                                    <input type='text' name='input_3.6' id='input_85_3_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_85_3_6' >Last<\/label>\n                                                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value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_85_9\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_85_9' >SSN<\/label><div class='ginput_container ginput_container_number'><input name='input_9' id='input_85_9' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_85_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_85_5' >Patient Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_85_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   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