REQUEST FOR INTRA-STATE ASSISTANCE - Nevada: Fill out & sign online

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Click ‘Get Form’ to open the REQUEST FOR INTRA-STATE ASSISTANCE - Nevada in the editor.
Begin by filling out the RECIPIENT DETAILS section. Enter the surname and given names, ensuring you select the appropriate gender option.
Provide your date of birth in the designated field, followed by details about your clinical unit and transplant unit.
Input your hospital reference number (MRN) and include information about your treating consultant and requesting doctor’s name.
In the URGENT LIST REQUEST section, indicate the urgency type by selecting either STATE URGENT or NATIONAL URGENT, and provide a reason for the request.
Attach any necessary approval documentation as required, ensuring you check off if it is from the State Approval Committee or Renal Transplant Advisory Committee Chairperson.
Finally, complete the TRANSPLANT UNIT SIGN-OFF section with full name, position, signature, and date before submitting your form.

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