Please note the following:
  • This form is to be completed by a referring physician or APRN.
  • A representative from the Heart Failure Infusion Program will contact you within one business day.
  • If you would rather download a form that you can fill out and fax to us, click here.
 
(* = Required)
  Patient Information:
   * Patient Name:
  * Date of Birth:
  * Gender: Male   Female
* Home Phone:
Cell Phone:
Primary Insurance: Company 
Policy #   
Secondary Insurance: Company 
Policy #   
  Referring Physician/APRN Information:
  * Physician/APRN Name:
Practice Name:
  * Phone:
Fax:
Email Address:
* Preferred Means of Communication: Phone   Fax   Email
* Reason for Referral:


Enter code shown above:
 
 

 

Note: If you would rather download a form that you can fill out and fax to us, use the link below:

Heart Failure Infusion Program Referral (PDF Format)

Please send the form and the following information to 860-545-3269 ATTN: Infusion Center.  We will review this information and contact the patient to schedule his/her initial appointment.

  • Patient Demographics
  • Recent Progress Notes
  • Medication List
  • Recent Labs
  • Echocardiogram
Infusion Referral form