3635 Vista Ave.
St. Louis, MO 63110
1
KIDNEY/PANCREAS
REFERRAL PACKET
Please attach the following information with each application.
1. Patient’s
history and physical (less than one year old).
2. Recent labs, current medication list and radiology results (most
recent). Please include most recent dry weight along with the date.
3. Copy of current insurance cards (back & front); If not sending cards
complete page 4.
4. Copy of the End Stage Renal Disease Medical Evidence
report (2728 form) from your dialysis center if applicable.
5. Copy of current social work annual assessment form.
6. PPD Test.
Transplant Office Phone:
314-577-8867
Referral Fax:
314-268-5132
3635 Vista Ave.
St. Louis, MO 63110
2
Transplant Referral Packet
Date: ____________________________ Type of Application Kidney
Kidney/Pancreas
Patient Information
Name:
DOB: Sex: Male / Female SSN: Address:
City: State: Zip: Marital Status
(check please) Single Married Divorced Widow Home Phone #: Mobile #: Work #: Other # : Ethnicity/Race: White Hispanic African American Asian East Indian Native Hawaiian American Indian Other
Are you a U.S. citizen? Yes ___ No___ If “No”, what country? ______________________ Are you a legal resident? Yes ____ No ____
Do you speak English? Yes ____ No ____ If “No” what language? _____________________ Spouse’s Name: ______________________________ Tel#: _________________________ Do you have any religious or cultural beliefs that would prevent you from accepting blood products? If yes, please explain__________________________________________________ ____________________________________________________________________________ Next of Kin Tel#
Name and Relationship: Address/City/State/Zip: Emergency Contact Name
and Relationship: Tel#: Email Address:
3635 Vista Ave.
St. Louis, MO 63110
3
FINANCIAL INFORMATION
Medicare ID#: Effective Date: Date Applied: Case Worker:
Medicaid ID#: Effective Date: Date Applied: Case Worker:
PRIMARY INSURANCE INFORMATION Insured Name: SSN:
Insurance Company: Insured DOB:
Address: Phone: City: State: Zip:
Group #: Policy/ID #: Pre-Cert Phone #:
Eligibility Date: Relationship to Pt: SECONDARY INSURANCE INFORMATION
Insured Name: SSN:
Insurance Company: Insured DOB:
Address: Phone: City: State: Zip:
Group #: Policy/ID #: Pre-Cert Phone #: Eligibility Date:
PATIENT EMPLOYMENT INFORMATION Employer:
Job/Occupation:
Address: City: State: Zip:
Disability? Yes / No If yes, Date: Why?
Retired? Yes / No If yes, Date: Why? PARENT OR SPOUSE EMPLOYMENT INFORMATION
Employer: Job/Occupation:
Address: City: State: Zip:
Disability? Yes / No If yes, Date: Why?
3635 Vista Ave.
St. Louis, MO 63110
4
PHYSICIAN INFORMATION
Referring Physician: Phone: Referring Center:
Address: City: State: Zip:
Primary Care Physician: Phone:
Address: City: State: Zip:
DIALYSIS INFORMATION
Dialysis Center Name: Phone:
If currently on a waitlist…
Are you currently
on a transplant waitlist? Yes / No Country: Name of Center: Previous Transplant? Yes / No If previous Transplant/Location: Date: _____/____/_____
Type of Dialysis (check please) PD Hemodialysis Not yet on Dialysis Dialysis Days (If Applicable) M/W/F T/Th/Sat Dialysis Time
Date of first dialysis treatment:
Type of access: ____________________________ Location: _____________________________ History of clotting of access: _______________________________________________________ PPD test result: __________________
3635 Vista Ave.
St. Louis, MO 63110
5
PATIENT REQUEST TO BEGIN EVALUATION AND FINANCIAL CLEARANCE PROCESS
AND RELEASE OF MEDICAL INFORMATION
I request that Saint Louis University Hospital begins the financial clearance process and transplant evaluation for me. I understand that my insurance company(ies) will be contacted in order to start this process. I authorize my physicians to release my medical records to Saint Louis University Hospital. I authorize Saint Louis University Hospital to release any medical information pertaining to my diagnosis and /or treatment including but not limited to information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), laboratory test results, medical history, treatment, or any other such related information to: 1) representative of local, state or federal agencies in accordance with law; 2) Medicare; 4) my insurance company or its designated representatives; 5) any person(s) or entities financially responsible for my care or treatment; 6) employees and representatives of Saint Louis University Hospital for investigation and defense of any claim or cause of action, actual or potential, which is our may be asserted against Saint Louis University Hospital, and /or any member of the medical and house staff at Saint Louis University Hospital and or 7) individual or entities for quality improvement, educational, medical research, accreditation or other purposes customarily utilized by the hospital and medical staffs in carrying out their functions. The duration of this authorization is indefinite. I understand that this information may be and/or required to be released in order to obtain payment for my medical expenses incurred at Saint Louis University. I further authorize release of this information to health care providers associated with my care outside Saint Louis University Hospital to facilitate further health care.
Patient Name (PLEASE PRINT): ______________________________________________
Patient Signature: ___________________________________ Date: _______________
IMPORTANT! This application must be filled out completely, signed and dated by you. Please attach a copy of all of your insurance cards to this application. If you have any questions regarding this
application, please contact Saint Louis University Transplant Services office at 314-577-8867.
Please mail or fax application to: Saint Louis University Hospital - Transplant Services FDT 11th Floor 3635 Vista Ave.
St. Louis, MO 63110 314-268-5132 (FAX)
3635 Vista Ave.
St. Louis, MO 63110
1
LIVER TRANSPLANT
REFERRAL PACKET
Please attach the following information with each application.
1. Patient demographics sheet
2.
Patient’s
history and physical (less than one year old)
3
. Patient’s height and weight
4. Recent labs, current medication list and radiology results
(most recent)
5. Etoh/nicotine/drug abuse screen
6. Copy of current insurance cards (back & front)
7. PPD Test
8. Do you have any religious or cultural beliefs that would
prevent you from accepting blood products? If yes,
explain____________________________"
Transplant Office Phone:
314-577-8867
Referral Fax:
314-268-5132
3635 Vista Ave.
St. Louis, MO 63110
2
PATIENT REQUEST TO BEGIN EVALUATION AND FINANCIAL CLEARANCE PROCESS
AND RELEASE OF MEDICAL INFORMATION
I request that Saint Louis University Hospital begins the financial clearance process and transplant evaluation for me. I understand that my insurance company(ies) will be contacted in order to start this process. I authorize my physicians to release my medical records to Saint Louis University Hospital. I authorize Saint Louis University Hospital to release any medical information pertaining to my diagnosis and /or treatment including but not limited to information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), laboratory test results, medical history, treatment, or any other such related information to: 1) representative of local, state or federal agencies in accordance with law; 2) Medicare; 4) my insurance company or its designated representatives; 5) any person(s) or entities financially responsible for my care or treatment; 6) employees and representatives of Saint Louis University Hospital for investigation and defense of any claim or cause of action, actual or potential, which is our may be asserted against Saint Louis University Hospital, and /or any member of the medical and house staff at Saint Louis University Hospital and or 7) individual or entities for quality improvement, educational, medical research, accreditation or other purposes customarily utilized by the hospital and medical staffs in carrying out their functions. The duration of this authorization is indefinite. I understand that this information may be and/or required to be released in order to obtain payment for my medical expenses incurred at Saint Louis University. I further authorize release of this information to health care providers associated with my care outside Saint Louis University Hospital to facilitate further health care.
Patient Name (PLEASE PRINT): ______________________________________________
Patient Signature: ___________________________________ Date: _______________
IMPORTANT! This application must be filled out completely, signed and dated by you. Please attach a copy of all of your insurance cards to this application. If you have any questions regarding this
application, please contact Saint Louis University Transplant Services office at 314-577-8867.
Please mail or fax application to: Saint Louis University Hospital - Transplant Services FDT 11th Floor 3635 Vista Ave.
St. Louis, MO 63110 314-268-5132 (FAX)
