Patient Info
Is this a physician referral or self?
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Address
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City
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State
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Zip Code
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First Name
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Middle Name
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Last Name
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Email Address
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Name of person completing this form
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Title of person completing this form
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Personal Information
Birth Date
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Home Phone
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Patient Medical Information
Nephrologist or Nephrology Group
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On Dialysis
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Dialysis Unit
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Dialysis Schedule
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Date of First Dialysis
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ERSD Diagnosis
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Does patient have a living donor?
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List any other transplant facilities patient is listed
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Patient Demographics
Height
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Weight
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Is patient currently a smoker?
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Primary Insurance
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ID#
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Secondary Insurance
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ID#
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Documentation
If you have any of the following documentation, please upload with your request below.
If you do not have these documents to attach to this online request for consultation, please fax them to 217-788-4606. Please make sure that all documents have the patient's name and DOB on them.
If this is a self-referral, we will contact your physician to secure these necessary documents prior to consultation.
Copy of insurance card File is required
Medication List File is required
Progress Notes/H&P File is required
Radiology File is required
Current Lab File is required
Cardiac Testing File is required
Form 2728
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I request to be scheduled for an appointment for transplant evaluation at Memorial Health. I hereby authorize Memorial Health Transplant Services to access by clinical and financial records limited to information pertaining to my care as a transplant patient.
Name
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Date
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