Get Willis-knighton Health System Kidney And/or Pancreas Referral Form

Completing the Willis-Knighton Health System Kidney and/or Pancreas Referral Form online is a critical step in the referral process for transplant services. This guide will walk you through the necessary steps to ensure all sections are filled out accurately and completely.

Follow the steps to successfully complete the referral form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by selecting the type of transplant needed: Kidney, Pancreas, or both. This selection is crucial for directing your referral appropriately.
3. Fill in the patient information fields including last name, first name, address, phone numbers, and other personal details. Ensure all entries are correct to avoid delays.
4. Provide information about the patient's dialysis experience, including referring physician details, dialysis center contact information, and type of dialysis being administered.
5. Input relevant medical information regarding the patient’s condition such as the cause of organ failure, any allergies, and important health history including diabetes and infection status.
6. Complete the insurance information section by providing the primary policy holder's name, date of birth, insurance company, and plan details.
7. If applicable, answer the questions regarding history of cancer, substance abuse, and active infections. Documentation may be required for affirmative responses.
8. Gather and attach the required documents, which may include a recent history and physical report, care plan, and any additional medical documentation requested.
9. Once all fields are filled out and documents attached, review the form for accuracy. Save any changes made during the process.
10. Finalize by downloading or printing the completed form, or share it as needed for submission.

Complete your referral form online today to ensure timely processing.