Fax Transplant Request

FAX TRANSPLANT REQUEST

Health Plan: / Transplant Center:
Case Manager: / Coordinator:
Phone: 602-824-3839 / Phone:
Fax: 602-674-6674 / Fax:
Member Name: / ID#: / DOB:
Referring MD: / Transplant Surgeon:
Diagnosis: / ICD Code:
TRANSPLANT TYPE: / ☐Heart/Lung / ☐Multi-Visceral
☐ Allogeneic Related Stem Cell / ☐ Kidney – ☐Deceased Donor or ☐Living Donor / ☐ Pancreas after Kidney
☐ Allogeneic Unrelated Stem Cell / ☐ Kidney/Liver / ☐ Simultaneous Pancreas/ Kidney
☐ Autologous Stem Cell / ☐ Liver / ☐ Small Bowel
☐ Heart / ☐ Lung - ☐ Single or ☐ Double / ☐ Other
SERVICE REQUESTED: / ☐ Donor Search - ☐Related or ☐Unrelated / ☐Circulatory Assist Device (CAD)
☐Consultation ☐ 1 random drug & alcohol screen / ☐Auto Harvest ☐Donor Harvest / ☐Lodging ☐Transportation
☐Evaluation / ☐ Annual Pre Transplant Evaluation / ☐Dental
☐Transplant (Approval/Listing) / ☐Days 1-30 ☐Days 31-60 / ☐Other:

REQUIRED DOCUMENTATION: Below is the minimum documentation required to be considered a complete request. The Health Plan may require other information as needed to establishmedical necessity. All documentation must be from a US licensed professional.

☐ CONSULTATION / ☐ EVALUATION / ☐ TRANSPLANT
☐Comprehensive H&P - (within 90 days)
☐ Height/Weight
☐ Social history to include any past/present use of
tobacco, alcohol, and drugs
☐ Support system
☐Diabetic
☐ HgbA1C (within 90 days)
☐Liver
☐ MELD/PELD labs (within 30 days and all results
from same lab draw) OR
☐If HCC – Imaging showing HCC
☐Lung
☐ Pulmonary Function Tests
☐ Nicotine & cotinine level (within 30 days)
☐ HIV test results
☐Heart
☐Echocardiogram with ejection fraction
☐HIV test results
______
☐AUTO HARVEST
OROR
DONOR SEARCH - ☐RELATED ☐UNRELATED______
☐All information from Consult
☐ Random drug screens
☐All members - (21 and older) - 1 random
drug & alcohol screen
☐History of substance abuse within 3 years -
3 consecutive random drug & alcoholscreens / ☐ Consult DOS______
☐ All information listed under
Consultation
☐Notes from Consultation visit
(if applicable)
☐Random drug screens
☐All members - (21 and older) - 1 random
drug & alcohol screen
☐ History of substance abuse within
3 years – 3 consecutive random drug
alcoholscreens
☐ History of substance abuse within 3
years
☐ Evidence of ongoing rehabprogram
(must have 12months completed prior
to transplant listing)
☐ Kidney
☐ GFR if not dialysis dependent
☐ Lung
☐ 2 Nicotine & cotinine levels / ☐Evaluation date span
______to ______
☐ All information from consult/eval
☐All Transplant Committee Notes
☐ Colonoscopy (50 and older or 40 if a first degree
family history of coloncancer)
☐Mammogram(Female 40 and older)
☐PAP (All females 21 and older)
☐ GYN Clearance(If total hysterectomy)
☐Psych/Social Evaluation
☐ Primary AND secondary caregiverplan (caregivers
must be at least 18)
☐Laboratory results
☐ Infectious disease markers to includeHIV, Cocci, TB
☐CXR or QuantiFERON test (if positive TB)
☐ Current A1C (within 90 days)
☐ MELD/PELD labs (within 60 days and all results
from same lab draw)
☐Echo and/or stress test
☐ History of substance abusewithin 3 years
☐ Ongoing random drug & alcohol screens
☐Completion of 12months of rehab program
☐ Member signed contract with facility
☐ Agreement to enroll in post-transplantsubstance
abuse program x 12months
☐ Lung
☐ 3 Nicotine & cotinine levels
☐Dental Clearance
☐ Negative x-ray OR
☐ Dental clearance form

Disclaimer:This message is intended only for the use of the individual or entity to which it is addressed and may contain confidential and/or proprietary information. If you are not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is prohibited. If you received this communication in error, please notify the sender at the phone number above.

Revised 5/21/14