Get Uc Davis Health Kidney Transplant Referral Form 2020-2026

Filling out the UC Davis Health Kidney Transplant Referral Form online is an essential step for individuals seeking kidney transplant services. This guide provides a step-by-step approach to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the referral form online

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the referral date in the designated field. This helps document when the referral was made.
3. Fill in the last name and first name sections with the patient's information. Accurate identification is crucial.
4. Provide the complete address, including the city, state, zip code, and home phone number. These details will facilitate communication.
5. Enter the date of birth (DOB) and email address to ensure that all contact information is up-to-date.
6. Indicate whether the potential living donor is available by selecting 'Yes' or 'No' in the respective field.
7. Complete the patient demographics section by providing the patient's age, sex assigned at birth, and mobile phone number.
8. In the insurance section, list the insurance provider's name, benefits phone number, subscriber name, and subscriber ID. This information is necessary for coverage confirmation.
9. Address any special considerations, including preferred language and whether an interpreter is required by selecting the appropriate options.
10. Document any communication barriers that may exist, such as hearing loss or blindness.
11. In the medical history section, provide the patient's height, weight, and Body Mass Index (BMI). Ensure that this data is accurate for the evaluation.
12. For dialysis information, indicate the patient's dialysis status. Check the appropriate box based on whether the person is not on dialysis, on in-center hemodialysis (HD), or undergoing home HD.
13. Complete the dialysis center information, including the facility start date, dialysis center address, and contact numbers.
14. Fill out the provider information, including details for the nephrologist, renal case manager/social worker, and primary care physician. Accurate provider information is essential for coordinated care.
15. Answer the required additional information questions by selecting 'Yes' or 'No' as appropriate. Ensure that all relevant medical considerations are noted.
16. Review the entire form for completeness and accuracy. Once satisfied, you may proceed to save changes, download, print, or share the form as needed.

Complete your forms online today to ensure timely processing of your kidney transplant referral.