Intermountain Referral Form

• Patient Name *

• Patient Phone Number *
  Format: (000) 000-0000.

• Patient DOB *

  • Month
  • Day
  • Year

• Patient Email

• Referral type
  Cardiac Rehabilitation
  Pulmonary Rehabilitation

• Qualifying Event / Diagnosis *
  MI within the last 12 months
  Stable Angina
  PCI
  CHF (with reduced EF)
  CABG
  LVAD
  Valve repair / replacement
  Cardiac Transplantation
  COPD (Pulmonary Rehab)
  Long COVID-19 (Pulmonary Rehab)
  Other

• Qualifying Event / Diagnosis *
  COPD (Pulmonary Rehab)
  Long COVID-19 (Pulmonary Rehab)
  Other

• Please check to include
  Remote patient monitoring (RPM) of blood pressure and heart rate

• Please check to include
  Remote patient monitoring (RPM) of blood pressure and heart rate

• Additional Referral Notes

• Referring Physician Name *

• Office Phone Number *
  Format: (000) 000-0000.

• Referring Physician email *

• File Upload

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  Choose a file

  Drop files here to upload

  Browse Files
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  Choose a file

• Submit

• Should be Empty: