PDF SSM Health Transplant Center at Saint Louis University Hospital

SSM Health Transplant Center at Saint Louis University Hospital

REFERRAL PROCESS

1) Fax or mail completed referral packet to SSM Health Transplant Center.

2) If patient is on dialysis, Intake Coordinator will request medical records from dialysis unit. If patient is not on dialysis, Intake Coordinator will contact nephrologist's office for records.

3) Once records are received, our Program Manager, will review each case to see if patient meets minimum criteria for transplant.

4) If patient meets minimum criteria, they are assigned to a nurse coordinator. Nurse coordinator will contact patient to begin evaluation process. If patient does not meet minimum criteria for transplant, the patient and his/her referring physician will be notified.

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Referrals may be initiated over the phone. Please have patient or patient representative call the center.

SSM Health Transplant Center Main Office: 314-577-8867

Referral Fax: 314-268-5132

SSM Health Transplant Center at Saint Louis University Hospital FDT 11th Floor

3635 Vista at Grand St. Louis, MO 63110

SSM Health Transplant Center at Saint Louis University Hospital

TRANSPLANT REFERRAL PACKET

Transplant Type:

KIDNEY OR

KIDNEY/PANCREAS

Date: ____________________________

PATIENT INFORMATION

Name:

U.S. Citizen: Yes

No

DOB:

Sex: Male

Female SSN:

Address:

City:

State:

Zip:

Home Phone #:

Mobile #:

Work #:

Email Address:

Ethnicity/Race:

Of Hispanic origin: Yes No

Caucasian/ White Hispanic African American/ Black Asian

American Indian

Other ___________________________

Language/Citizenship: Do you speak English?:

Yes No

East Indian

Native Hawaiian

If NO, what language(s) do you speak? __________________________________________________________

Marital Status:

Single

Married

Divorced

Widow

Next of Kin Name and Relationship:

Phone:

Emergency Contact (other) Name and Relationship:

Phone:

314-577-8867

SSM Health Transplant Center

at Saint Louis University Hospital

INSURANCE INFORMATION

PLEASE ATTACH A COPY (FRONT AND BACK) OF YOUR INSURANCE CARDS. IF YOU DO NOT HAVE CARD COPIES, PLEASE COMPLETE THE SECTIONS BELOW

____________________________________________________________________________________

GOVERNMENT INSURANCE

Medicare ID#:

Effective Date:

Date Applied:

Medicaid ID#:

Effective Date:

Date Applied:

Case Worker:

____________________________________________________________________________________

Are you a Veteran of the United States Military? YES / NO If YES, what branch?

Insurance Company: Insured Name: Address: City: Group #: Eligibility Date:

Insurance Company: Insured Name: Address: City: Group #: Eligibility Date:

COMMERCIAL OR PRIVATE INSURANCE

State: Policy/ID #:

SSN: Phone: Zip:

OTHER INSURANCE

State: Policy/ID #:

SSN: Phone: Zip:

314-577-8867

Nephrologist:

SSM Health Transplant Center at Saint Louis University Hospital

PHYSICIAN INFORMATION Phone:

Address:

City:

State:

Zip:

Primary Care Physician:

Phone:

Address:

City:

State:

Zip:

HEALTH INFORMATION

Current Height: ______________________

Current Weight: _____________ __ kg / lbs

Do you have any religious or cultural beliefs that would prevent you from accepting blood products? YES / NO If yes, please, explain _____________________________________________

Are you currently being evaluated or are you on a transplant waitlist? YES / NO If yes: Name of Center: _________________________________________City/State:_______________

Have you had a previous transplant? YES / NO If yes: Name of Center:__________________________________________City/State:______________ Date: _____/____/_____

Do you have any potential living donors for transplantation? YES / NO

Are you currently on dialysis? YES / NO If YES, please complete section below:

Dialysis Center Name:

Address:

City:

Type of Dialysis (check please)

Dialysis Days:

M/W/F

Date of first dialysis treatment:

State: PD T/Th/Sat

Phone:

Zip:

In-Center Hemodialysis

Home Hemodialysis

Daily Dialysis Time:

314-577-8867

SSM Health Transplant Center at Saint Louis University Hospital

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: SSM Health Transplant Center at St. Louis University Hospital FDT 11th Floor 3635 Vista Ave. St. Louis, MO 63110

314-268-5132 (FAX)

314-577-8867

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