NEPHROLOGY REFERRAL FORM PATIENT INFORMATIONPATIENT INSURANCE INFORMATION Last Name First Name Primary Medical Insurance Medical Insurance Phone Social Security No Date of Birth Subscriber NameSex.
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How to fill out the CA SSRx Nephrology Referral Form_DSA online
Filling out the CA SSRx Nephrology Referral Form_DSA online is a straightforward process that ensures accurate patient information is conveyed for referral. This guide will provide you with step-by-step instructions to effectively complete each section of the form.
Follow the steps to successfully complete the form online.
- Press the ‘Get Form’ button to obtain the form and access it in your online document editor.
- Begin by entering the patient information. Provide the last name and first name of the patient, along with their date of birth, social security number, and weight and height details.
- Next, input the patient's insurance information, including the primary medical insurance name, insurance phone number, subscriber name, and relevant card details such as Rx Card (PBM), group number, bin number, and PCN number.
- Continue to fill out the treatment arrangements section by specifying the start date for the treatment and whether medications will be shipped to the patient’s home or the doctor’s office. Indicate who will provide the necessary teaching regarding the treatment.
- In the diagnosis section, select the appropriate diagnosis option based on the patient's condition. If applicable, provide an alternative diagnosis.
- Complete the medical assessment section by answering the questions related to iron store evaluation. Provide the dates and results for transferrin saturation and ferritin levels, and document blood pressure information.
- Identify if the patient has been treated previously for their condition by indicating which medications failed if applicable. Specify whether the patient is currently on therapy and list any relevant medications.
- Fill out the prescription information by selecting the required medications along with the dosage options, administration routes, and additional details for frequency and quantity.
- Lastly, ensure the physician’s signature, name, contact information, NPI, and DEA information are provided in the designated area. Review all segments filled out for accuracy.
- Once all the required fields are completed, save any changes made, and choose to either download, print, or share the form as needed.
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At what point do you refer to nephrology?
Indications for referral vary across guidelines but there is one commonality: Patients with a severely decreased estimated glomerular filtration rate (eGFR) of < 30 mL/min per 1.73 m2 require prompt referral to a nephrologist for comanaged care.
When should a patient be referred to nephrology?
Indications for referral vary across guidelines but there is one commonality: Patients with a severely decreased estimated glomerular filtration rate (eGFR) of < 30 mL/min per 1.73 m2 require prompt referral to a nephrologist for comanaged care.
What GFR number requires dialysis?
There are five Stages of CKD, with the most advanced being Stage 5, with an estimated glomerular filtration rate (eGFR) of less than 15. It is generally patients with Stage 5 CKD that are considered candidates to start dialysis therapy or be considered for kidney transplantation.
What stage of kidney disease do you refer to nephrology?
As stage 3 progresses, a patient should see a nephrologist (a doctor who specializes in treating kidney disease).
What is early referral in nephrology?
In this review, referral is defined as the time period between first nephrology evaluation and initiation of dialysis; early referral is more than one to six months, whereas late referral is less than one to six months prior to starting dialysis.
What is the criteria for referral to nephrology?
Referral could be considered for any one of the following: Hypertension refractory to treatment with 4 or more antihypertensive agents. Persistent abnormalities of serum potassium or other electrolytes. Recurrent or extensive nephrolithiasis. Hereditary kidney disease (e.g. polycystic kidney disease).
What are the indications for referral to nephrologist in CKD?
In chronic kidney disease (CKD), referral to nephrology is based on Kidney Disease: Improving Global Outcomes 2012 guidelines and is generally indicated when the estimated glomerular filtration rate (eGFR) is <30 mL/min/1.73 m2 or when there is a rapid decline of eGFR, elevated urinary albumin:creatinine ratio (>300 mg ...
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