Referral/Requisition Forms

Form Name HH-DPC# Rev. Posted
Cardiac Rehabilitation Referral 571979 07/15 08/14/15
Diabetes LifeCare - Consult for Surgical Weight Loss Patient 572025 06/10 12/23/10
Diabetes LifeCare - Plan of Care 571780 10/15 12/21/15
Diabetes LifeCare - Plan of Care (for pregnant patients only) 571448 12/15 12/21/15
EEG Laboratory Outpatient Referral Form 546371 01/18 01/11/18
Electromyography (EMG) Laboratory Referral 571152 01/18 01/11/18
Imaging Center Requisition 546231 09/12 11/28/12
Request for Non-Invasive Cardiology Evaluation 571882 05/14 05/22/14
Request for Outpatient Echocardiography Evaluation 546579 05/14 05/22/14
Request to Amend Protected Health Information (English) 572575 10/19 03/13/20
Request to Amend Protected Health Information (Spanish) 572575-SP 10/19 03/13/20
Sleep Disorder Center Referral Form 571922 05/16 08/03/16

Miscellaneous Documents/Forms

Form Name HH-DPC# Rev. Posted
COVID-19 Vaccination Clinical Consent & Authorization for Disclosure 577653 08/21 04/06/22
Diabetes Service Nurse Practitioner Follow-Up 572306 08/13 09/30/13
Hartford Hospital "DO NOT USE" Abbreviations n/a 12/03 11/24/10
Pain Treatment Center New Patient Consult n/a 05/14 05/08/14
Pain Treatment Center Progress Note n/a 05/14 05/08/14
Patient Guide to Surgery 570186 03/05 12/01/06
Patient Guide to Diabetes Medications Before Surgery (English) 571140 12/07 02/12/08
Patient Guide to Diabetes Medications Before Surgery (Spanish) 571140 12/07 02/12/08
Transplant Program Medication Renewal/Request List n/a n/a 01/06/11
Trauma Progress Note 571588 09/11 03/13/12
Trauma Supplemental Resuscitation Record 571138 11/11 03/13/12
Trauma Tertiary Survey 571916 10/11 03/13/12

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