Kidney Transplant Referral

Patient Information

First Name

Last Name

Birth Date

Social Security Number

Email Address

Phone Number

Street Address

City

State

Zip Code

Gender Identity

Sex Assigned at Birth

Height

Weight

BMI

Are you a current or previous smoker?

Yes, I am a smoker, or I was previously a smoker.No, I am not a smoker.

Medical History

Please provide complete health history including past surgeries and known health problems.

What is the primary cause of the patient's end stage renal disease?

Dialysis Center Name

Date of Dialysis Initiation

Please list any other transplant centers the patient is listed (active/inactive)

Insurance Information

Primary Insurance

Primary Insurance Company

In which state is the Wellmark/Blue Cross Blue Shield insurance issued?

Member/Policy Number

Group Number

Employer Issuing Insurance

Subscriber Name

Subscriber Birth Date

Company Phone Number

Preauthorization Number

Street Address

City

State

Zip code

Do you have secondary insurance?

YesNo

Secondary Insurance Company

In which state is the Wellmark/Blue Cross Blue Shield insurance issued?

Member/Policy Number

Group Number

Employer Issuing Insurance

Subscriber Name

Subscriber Birth Date

Company Phone Number

Preauthorization number

Street Address

City

State

Zip code

Referring Physician Information

First Name

Last Name

Phone Number

Fax Number