Get Davita Admissions Intake Form

Completing the Davita Admissions Intake Form online is a crucial step for securing a placement in outpatient dialysis. This guide will provide you with clear, step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to fill out the form online successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by entering your Contact Number, Hospital/Practice information, and the name of the Attending Nephrologist responsible for the outpatient dialysis care.
3. Fill in the Patient Name along with the First Day of Dialysis Ever and select the appropriate Diagnosis options from the provided list.
4. Indicate the Modality by selecting one of the following: In-Center Hemo, Nocturnal, Home Hemo, or PD. Provide your Preferred Schedule and the planned Treatment Duration by entering the hours and minutes.
5. Specify the Treatment Frequency by checking the appropriate box (2x, 3x, 4x, or Other) and provide details of the Access type, including Hep B Antigen (HBsAg) Status.
6. Enter the anticipated DaVita Start Date and any requested Facility(s) or Zip Code. You may also indicate if the patient has special needs and their flexibility regarding scheduling.
7. Prior to admission, ensure you collect and Fax the necessary information as stated under STEP 2, including results for Hep B Antigen, Physician Dialysis Order, and other medical documents.
8. After completing all fields of the form, review your entries for accuracy. Save your changes, then download, print, or share the completed form as needed.

Start filling out your Davita Admissions Intake Form online today for a smooth admission process.