Kidney Pancreas Transplant Review And Referral Form printable pdf download

RENAL/PANCREAS TRANSPLANT REVIEW AND REFERRAL FORM

General Information

Please find enclosed UNC Hospitals’ Transplant Review and Referral Form for the renal/

pancreas transplant program. This form will streamline the process of referral for you,

as well as give us important information with which to start evaluation for your patient.

We ask that you use both parts of this form when you are requesting a transplant

evaluation, unless you have indicated that a patient is clearly not a transplant candidate

at this time. In this case, you do not need to complete Part II. In either event, a copy of

our transplant surgeon’s opinion will be returned to you in order to comply with yearly

review regulations. All review forms should be submitted to:

UNC Center for Transplant Care

Kidney Transplant Program

101 Manning Dr. RM 4056

Chapel Hill, NC 27514

FAX: 984-974-0888

Phone: 984-974-9950

When Parts I and II are received, we will contact the patient and explain the process of

scheduling an initial appointment for our transplant orientation class.

Part I will be

returned to the referring nephrologist. The patient will be sent a letter with information

about times and dates of upcoming orientation classes and a copy will be sent to you.

In addition to receiving written information, patients attending the transplant orientation

class will attain a general overview of the evaluation process, risks and benefits of renal

transplant for treatment of ESRD, and deceased versus live donor issues.

After

attending orientation class and receiving insurance authorization, the patient can

proceed with the medical evaluation. Initial appointments (i.e. labs, chest x-ray, EKG,

Nephrology, Cardiology, etc.) will be scheduled for the patient. Patients will be notified

of all appointments by letter.

For select patients, the orientation class may be omitted (those who are non-English

speakers, hearing impaired or with exceptional medical considerations). These patients

will receive transplant education individually with their nurse coordinator and the

transplant team.

During successive trips to the hospital, and unless contraindicated, we will always try to

schedule as many appointments as feasible so that the patient can complete his/her

evaluation in a timely manner.

We hope this will be helpful to everyone involved in the transplant process, and we thank

you for suggestions and your continuing interest.

February 2015

Kidney Pancreas Transplant Review And Referral Form