Duke Mcoc 9426 Form PDF Details

Navigating the various forms and documents required for specialized medical treatment can often seem daunting. Within this domain, the Duke MCOC 9426 form plays an essential role for those seeking consultation or intervention from Duke Transplant Services, particularly within their Lung and Heart/Lung Transplant Program. This particular form serves as a comprehensive patient referral tool, capturing a broad range of essential information. It encompasses patient demographic details—including contact information and social security number—emergency contact particulars, referring physician data, and detailed patient insurance information, with instructions to attach copies of the insurance card. Additionally, it requests specific clinical data about the patient, such as height, weight, smoking history, oxygen usage, and required medical documents like test results and operative reports. Not only does this form streamline the referral process by consolidating critical information, but it also helps the transplant team at Duke assess the patient's eligibility and readiness for a potential life-altering procedure. Located in Durham, NC, Duke Transplant Services provides a toll-free number and various means of submission (including USPS and FedEx/UPS), reflecting their commitment to accessibility and efficient patient care.

QuestionAnswer
Form NameDuke Mcoc 9426 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesduke gi referral form, duke referral form, duke university lung transplant referral form, duke lung transplant referral

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT REFERRAL FORM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duke Transplant Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lung and Heart/Lung Transplant Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toll-Free: 800-249-5864, option 1

 

 

 

 

 

 

 

 

 

USPS: Box 102347, Durham, NC 27710

 

 

 

 

Local: 919-613-7777, option 1

 

 

 

 

 

 

 

 

 

FedEx/UPS: 330 Trent Drive, Room 133

 

 

 

 

Fax: 919-681-5770

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hanes House, Durham, NC 27710

Patient Demographic Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

Patient Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

State:

 

 

 

 

Zip:

 

Social Security Number:

 

 

 

Date of Birth:

 

 

 

 

Gender: M F Race:

 

Home Phone:

 

 

 

Work Phone:

 

 

 

 

 

 

 

 

 

 

 

Cell Phone:

 

 

 

Patient E-mail:

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact:

 

 

 

Phone:

 

 

 

 

Relationship:

 

Referring Physician Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Name (if applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

 

 

 

 

Zip:

 

Office Phone:

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person Completing This Form:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Insurance Information (attach copy of both sides of card)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policyholder’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policyholder’s DOB:

 

 

 

 

Insurance Phone:

 

 

 

 

 

 

 

 

 

 

 

Policy Number:

 

 

 

 

Group Number:

 

 

 

 

 

 

 

 

 

 

 

Secondary Insurance Information (attach copy of both sides of card)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policyholder’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policyholder’s DOB:

 

 

 

 

Insurance Phone:

 

 

 

 

 

 

 

 

 

 

 

Policy Number:

 

 

 

 

Group Number:

 

 

 

 

 

 

 

 

 

 

 

Patient General Clinical Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Available, Duke History Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Height:

 

 

 

 

Patient Weight:

 

 

 

 

 

 

 

 

 

 

 

Smoking Cessation Date:

 

 

 

 

Oxygen Use at Rest:

 

 

 

 

 

 

 

at Exertion:

 

Required Medical Information

ƒƒArterial blood gas and pulmonary function test (PFT) results from the last 12 months

ƒƒRecent clinic notes including list of current medications

ƒƒReports of any cardiology studies, including heart catheterization, echo, and stress test

ƒƒRecent chest x-ray report

ƒƒOperative reports from any thoracic surgeries

ƒƒRecent lab results including complete blood count and comprehensive metabolic panel

dukehealth.org/transplant

Revised 03/2012 MCOC-9426

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