Get Or Transplant Request Form 2011-2025

Filling out the OR Transplant Request Form is an essential step in initiating a transplant request. This guide provides comprehensive, step-by-step instructions to help you navigate the form efficiently and accurately.

Follow the steps to fill out the OR Transplant Request Form online:

1. Press the ‘Get Form’ button to access the OR Transplant Request Form and open it in your preferred editor.
2. Begin by entering your personal details, including the date of request, the name of the person completing the form, and their contact information such as phone number and fax number.
3. Fill in the member’s name, date of birth, and recipient ID number. Ensure that all information is accurate to avoid any delays in processing.
4. Provide the physician's name, along with their phone number and fax number, ensuring all contact details are correct.
5. Specify the facility where the transplant will occur and include the respective fax number.
6. Indicate the anticipated admission date and the expected length of stay (LOS) for the inpatient procedure.
7. Enter the ICD-9 code and CPT code relevant to the transplant procedure being requested.
8. Detail the type of transplant proposed and include the latest HIV test result along with the test date.
9. If applicable, provide any evidence of contraindications for the type of transplant, citing the relevant DMAP policies, rules, and guidelines.
10. List any alternative treatments considered, including the history of treatment attempts and reasons for ruling out options, ensuring the rationale is included.
11. Confirm the five-year survival rate associated with the transplant. Indicate 'Yes' or 'No' as appropriate.
12. Sign and date the form at the bottom, ensuring that the signature of the transplant center physician is included.
13. Once all fields are completed, ensure to review the information for accuracy. You can then save your changes, download, print, or share the form as needed.

Start completing your OR Transplant Request Form online today!