{"id":718,"date":"2024-11-15T11:04:42","date_gmt":"2024-11-15T17:04:42","guid":{"rendered":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/?page_id=718"},"modified":"2024-11-15T11:04:56","modified_gmt":"2024-11-15T17:04:56","slug":"fmp-eld-clinic-referral-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/fmp-eld-clinic-referral-form\/","title":{"rendered":"FMP ELD Clinic Referral Form"},"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_193' style='display:none'><div id='gf_193' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_193' id='gform_193'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/718#gf_193' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_193' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_193_1\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >Thank you for your interest in the UAB Environmental Lung Disease Clinic. Your completion of all the fields below and attachment of medical records will ensure that there are no unnecessary delays in the evaluation of your patient.<\/div><div id=\"field_193_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_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_193_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_193_3\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_3' >Please select the option that best describes you.<\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_193_3' class='large gfield_select'     aria-invalid=\"false\" ><option value='I am a referring provider' >I am a referring provider<\/option><option value='I am a patient or guardian' >I am a patient or guardian<\/option><option value='Third party referrer (DOL, legal, workman\u2019s comp, other)' >Third party referrer (DOL, legal, workman\u2019s comp, other)<\/option><\/select><\/div><\/div><div id=\"field_193_4\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_4' >Request Priority<\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_193_4' class='large gfield_select'     aria-invalid=\"false\" ><option value='Urgent (1-2 weeks)' >Urgent (1-2 weeks)<\/option><option value='4 weeks' >4 weeks<\/option><option value='6 weeks-3 months' >6 weeks-3 months<\/option><option value='First available' >First available<\/option><\/select><\/div><\/div><fieldset id=\"field_193_5\" 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_193_5'>\n                            \n                            <span id='input_193_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_193_5_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_193_5_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_193_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_193_5_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_193_5_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_193_6\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_6' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_193_6' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   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field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_8' >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_8' id='input_193_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_193_17\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_17' >Alternate 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_17' id='input_193_17' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   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                           <span id='input_193_9_6_container' class='name_last' >\n                                                    <input type='text' name='input_9.6' id='input_193_9_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_193_9_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_193_10\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_10' >NPI<\/label><div class='ginput_container ginput_container_number'><input name='input_10' id='input_193_10' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_193_11\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below 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id=\"field_193_13\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_193_13' >Additional Remarks<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_193_13' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_193_15\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p><strong>Please upload or fax our office with relevant pulmonary (lung) diagnosis records only.<\/p><\/strong>\n<ul>\n<li>Copy of front\/back of insurance cards (if available)<\/li>\n<li>Most recent clinic notes<\/li>\n<li>Most recent pulmonary testing reports (pulmonary function testing, ABGs, CPET, walk test)<\/li>\n<li>For testing with associated images (Chest Xray, CT, PET) please send a copy of the most recent 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