Intermountain Referral Form Intermountain Referral Form Patient Name* Patient Phone Number* Format: (000) 000-0000. Patient DOB* -Month -DayYear Patient Email Referral type Cardiac RehabilitationPulmonary Rehabilitation Qualifying Event / Diagnosis* MI within the last 12 monthsStable AnginaPCICHF (with reduced EF)CABGLVADValve repair / replacementCardiac TransplantationCOPD (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 Browse FilesDrag and drop files here Choose a file Drop files here to uploadBrowse FilesDrag and drop files here Choose a file Browse FilesCancelof Cancelof Submit Should be Empty: