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KIDNEY TRANSPLANT REFERRAL FORM Referral Criteria for Kidney Transplantation: Preemptive kidney transplantation is the preferred form of renal replacement therapy and should be encouraged where feasible.

How to fill out kidney transplant referral form

How to fill out kidney transplant referral form:

1. Start by carefully reading the instructions on the form. It is important to understand the requirements and provide accurate information.
2. Begin with your personal details, including your full name, date of birth, contact information, and social security number.
3. Fill in your medical history, including any relevant information about your previous or existing kidney conditions, treatments, medications, and surgeries.
4. Provide details about your healthcare provider or primary care physician, including their name, contact information, and any specific instructions they have provided regarding the referral.
5. Include information about your insurance coverage, such as your insurance provider, policy number, and any specific requirements or pre-authorization needed for the transplant referral.
6. Attach any relevant medical records, test results, or documentation that supports your need for a kidney transplant.
7. If you have a living donor, provide their information, including their relationship to you, contact details, and any necessary consent forms.
8. Review the completed form to ensure all the required fields are filled accurately and completely.
9. Sign and date the form, and make a copy for your records before submitting it to the designated recipient.

Who needs kidney transplant referral form:

1. Individuals who have been diagnosed with end-stage renal disease (ESRD) and are seeking a kidney transplant may require a kidney transplant referral form.
2. Patients with other kidney-related conditions that make them suitable candidates for a kidney transplant, as determined by their healthcare provider, may also need to fill out this form.
3. Both potential recipients and living donors may need to complete a kidney transplant referral form, depending on the specific requirements of the transplant center or healthcare facility.

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What is kidney transplant referral form?

Kidney transplant referral form is a document used to refer a patient to be evaluated for a kidney transplant.

Who is required to file kidney transplant referral form?

Medical professionals overseeing the patient's kidney health are required to file the kidney transplant referral form.

How to fill out kidney transplant referral form?

The form can be filled out by providing the patient's medical history, current kidney function, and any other relevant information.

What is the purpose of kidney transplant referral form?

The purpose of the form is to initiate the evaluation process for a potential kidney transplant recipient.

What information must be reported on kidney transplant referral form?

Information such as the patient's medical history, current kidney function, and any previous transplant surgeries must be reported on the form.