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Filling out the Renal Referral Form can seem daunting, but this guide is here to support you through each step of the process. By following these instructions, you will provide all required information accurately and efficiently.

Follow the steps to complete the referral form effectively.

1. Click the ‘Get Form’ button to access the Renal Referral Form and open it in your preferred online document editor.
2. Begin with identifying the type of referral by selecting one of the options: Kidney, Kidney/Pancreas, or Pancreas only. This helps direct the referral to the appropriate program.
3. Enter the referring nephrologist's name and contact number to facilitate communication regarding the patient's referral.
4. Fill in the 'Referral Date' to indicate when the referral is made. This is important for tracking the timeline of patient care.
5. Provide the patient's personal details: full name, Social Security Number, date of birth, age, race, and sex. This information is crucial for patient identification.
6. Input the patient's home and cell phone numbers, as well as their residential address, to ensure that communication can be directed appropriately.
7. Enter the patient's email address, which may be used for correspondence and additional communication.
8. Specify an emergency contact's name, their relationship to the patient, and their phone number, ensuring there is a point of contact in case of emergencies.
9. Indicate the languages the patient reads and speaks, including whether they can read and speak English.
10. If the patient has any special needs, provide details about those needs to ensure proper accommodations are made.
11. Record the patient’s dialysis center information, including name and phone number, along with the start date and type of dialysis.
12. Fill in the dialysis schedule to provide clarity on the patient's treatment routine.
13. Complete the insurance information section, ensuring to include copies of both the front and back of the insurance cards.
14. Provide medical information, including the cause of renal failure, height, weight, and any additional comments that may be relevant to the patient's condition.
15. Enter the name and phone number of the person completing the form, along with their fax number to receive follow-up information.
16. Once all sections of the form have been filled out completely and accurately, you can save your changes, download the document, print it, or share it as necessary.

Complete all required documents online for a seamless referral process.