816-932-3973 fax-2026

1. Click ‘Get Form’ to open the 816-932-3973 fax in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's name, date of birth, gender, social security number, and phone number in the designated fields.
3. Next, move to the Physician Information section. Input the nephrologist's name, phone number, and fax number accurately.
4. In the Referral Information section, provide details about the dialysis center including its name, office phone, and fax number. Specify the type of dialysis and start date.
5. Indicate the dialysis days by checking off Mon through Sat as applicable.
6. For Insurance Information, if cards are available, ensure they are faxed to 816-932-3973. If not available, fill in primary and secondary insurance details along with cardholder information.

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