# Intermountain Referral Form

- **Patient Name***

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

- **Patient DOB***  
  
   -Month -DayYear

- **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**  
  
  
  Browse Files

Drag and drop files here
  
  Choose a file
  
  
  
  Drop files here to upload

- **Submit**

- **Should be Empty:**