Get Liver Transplant Request For Coverage Form - Tufts Health Plan

Completing the Liver Transplant Request For Coverage Form is an essential step in securing coverage for a liver transplant. This guide will help you navigate the form online, ensuring all necessary information is included for a successful submission.

Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to access the Liver Transplant Request For Coverage Form and open it for editing.
2. Begin by filling out the demographic information section. Provide the patient's name, ID number, date of birth, primary care provider, and details regarding the transplant physician and facility. Be precise and ensure legibility to avoid delays.
3. Complete the current diagnosis section by including the ICD 9 code and MELD score. Ensure this information is accurate as it plays a critical role in the transplant assessment.
4. Answer the questions regarding the patient's conditions. For each question, choose 'Yes' or 'No' appropriately, providing clear responses regarding the patient's health status and any concerns relevant to the transplant process.
5. Gather the required documentation including a Letter of Medical Necessity, medical records, and laboratory assessments. Attach these documents clearly labeled as indicated.
6. Review all entries for accuracy and completeness, ensuring that no sections are omitted or incomplete.
7. After finalizing the form, save your changes. Depending on your needs, you can download, print, or share the completed form with the appropriate parties.

Start filling out the Liver Transplant Request For Coverage Form online today for a smoother coverage process.