KIDNEY/PANCREAS REFERRAL PACKET Please attach the following information with each application.

Transcription

1 KIDNEY/PANCREAS REFERRAL PACKET Please attach the following information with each application. 1. Patient s history and physical (less than one year old). 2. Recent labs, current medication list and radiology results (most recent). Please include most recent dry weight along with the date. 3. Copy of current insurance cards (back & front); If not sending cards complete page Copy of the End Stage Renal Disease Medical Evidence report (2728 form) from your dialysis center if applicable. 5. Copy of current social work annual assessment form. 6. PPD Test. Transplant Office Referral Fax:

2 Transplant Referral Packet Date: Type of Application Kidney Patient Information Name: DOB: Sex: Male / Female SSN: Marital Status (check please) Home Phone #: Mobile #: Single Married Divorced Widow Work #: Other # : Kidney/Pancreas Ethnicity/Race: White Hispanic African American Asian East Indian Native Hawaiian American Indian Other Next of Kin Name and Relationship: Address/City/State/Zip: Are you a U.S. citizen? Yes No If No, what country? Are you a legal resident? Yes No Do you speak English? Yes No If No what language? Spouse s Name: Tel#: Do you have any religious or cultural beliefs that would prevent you from accepting blood products? If yes, please explain Tel# Emergency Contact Name and Relationship: Tel#: 2

3 Medicare ID#: Date Applied: Medicaid ID#: Date Applied: Insured Name: Insurance Company: FINANCIAL INFORMATION Effective Date: Case Worker: Effective Date: Case Worker: PRIMARY INSURANCE INFORMATION SSN: Insured DOB: Group #: Policy/ID #: Pre-Cert Phone #: Eligibility Date: Insured Name: Insurance Company: Relationship to Pt: SECONDARY INSURANCE INFORMATION SSN: Insured DOB: Group #: Policy/ID #: Pre-Cert Phone #: Eligibility Date: PATIENT EMPLOYMENT INFORMATION Employer: Job/Occupation: Disability? Yes / No If yes, Date: Why? Retired? Yes / No If yes, Date: Why? PARENT OR SPOUSE EMPLOYMENT INFORMATION Employer: Job/Occupation: Disability? Yes / No If yes, Date: Why? Retired? Yes / No If yes, Date: Why? 3635 Vista Ave. 3

4 PHYSICIAN INFORMATION Referring Physician: Referring Center: Primary Care Physician: DIALYSIS INFORMATION Dialysis Center Name: If currently on a waitlist Are you currently on a transplant waitlist? Yes / No Country: Name of Center: Previous Transplant? Yes / No If previous Transplant/Location: Date: / / Type of Dialysis (check please) PD Hemodialysis Not yet on Dialysis Dialysis Days (If Applicable) M/W/F T/Th/Sat Dialysis Time Date of first dialysis treatment: Type of access: Location: History of clotting of access: PPD test result: 4

5 PATIENT REQUEST TO BEGIN EVALUATION AND FINANCIAL CLEARANCE PROCESS AND RELEASE OF MEDICAL INFORMATION I request that Saint Louis University Hospital begins the financial clearance process and transplant evaluation for me. I understand that my insurance company(ies) will be contacted in order to start this process. I authorize my physicians to release my medical records to Saint Louis University Hospital. I authorize Saint Louis University Hospital to release any medical information pertaining to my diagnosis and /or treatment including but not limited to information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), laboratory test results, medical history, treatment, or any other such related information to: 1) representative of local, state or federal agencies in accordance with law; 2) Medicare; 4) my insurance company or its designated representatives; 5) any person(s) or entities financially responsible for my care or treatment; 6) employees and representatives of Saint Louis University Hospital for investigation and defense of any claim or cause of action, actual or potential, which is our may be asserted against Saint Louis University Hospital, and /or any member of the medical and house staff at Saint Louis University Hospital and or 7) individual or entities for quality improvement, educational, medical research, accreditation or other purposes customarily utilized by the hospital and medical staffs in carrying out their functions. The duration of this authorization is indefinite. I understand that this information may be and/or required to be released in order to obtain payment for my medical expenses incurred at Saint Louis University. I further authorize release of this information to health care providers associated with my care outside Saint Louis University Hospital to facilitate further health care. Patient Name (PLEASE PRINT): Patient Signature: Date: IMPORTANT! This application must be filled out completely, signed and dated by you. Please attach a copy of all of your insurance cards to this application. If you have any questions regarding this application, please contact Saint Louis University Transplant Services office at Please mail or fax application to: Saint Louis University Hospital - Transplant Services FDT 11 th Floor 3635 Vista Ave (FAX) 5

6 LIVER TRANSPLANT REFERRAL PACKET Please attach the following information with each application. 1. Patient demographics sheet 2. Patient s history and physical (less than one year old) 3. Patient s height and weight 4. Recent labs, current medication list and radiology results (most recent) 5. Etoh/nicotine/drug abuse screen 6. Copy of current insurance cards (back & front) 7. PPD Test 8. Do you have any religious or cultural beliefs that would prevent you from accepting blood products? If yes, explain " Transplant Office Referral Fax:

7 PATIENT REQUEST TO BEGIN EVALUATION AND FINANCIAL CLEARANCE PROCESS AND RELEASE OF MEDICAL INFORMATION I request that Saint Louis University Hospital begins the financial clearance process and transplant evaluation for me. I understand that my insurance company(ies) will be contacted in order to start this process. I authorize my physicians to release my medical records to Saint Louis University Hospital. I authorize Saint Louis University Hospital to release any medical information pertaining to my diagnosis and /or treatment including but not limited to information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), laboratory test results, medical history, treatment, or any other such related information to: 1) representative of local, state or federal agencies in accordance with law; 2) Medicare; 4) my insurance company or its designated representatives; 5) any person(s) or entities financially responsible for my care or treatment; 6) employees and representatives of Saint Louis University Hospital for investigation and defense of any claim or cause of action, actual or potential, which is our may be asserted against Saint Louis University Hospital, and /or any member of the medical and house staff at Saint Louis University Hospital and or 7) individual or entities for quality improvement, educational, medical research, accreditation or other purposes customarily utilized by the hospital and medical staffs in carrying out their functions. The duration of this authorization is indefinite. I understand that this information may be and/or required to be released in order to obtain payment for my medical expenses incurred at Saint Louis University. I further authorize release of this information to health care providers associated with my care outside Saint Louis University Hospital to facilitate further health care. Patient Name (PLEASE PRINT): Patient Signature: Date: IMPORTANT! This application must be filled out completely, signed and dated by you. Please attach a copy of all of your insurance cards to this application. If you have any questions regarding this application, please contact Saint Louis University Transplant Services office at Please mail or fax application to: Saint Louis University Hospital - Transplant Services FDT 11 th Floor 3635 Vista Ave (FAX) 2