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TRANSPLANT REQUEST FORM FamilyCare ... - FamilyCare, Inc. - familycareinc

TRANSPLANT REQUEST FORM FamilyCare ... - FamilyCare, Inc. - familycareinc 2025

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The document is a Transplant Request Form from FamilyCare Health Plans, outlining the necessary information and documentation required for requesting approval for organ transplants. It includes sections for patient details, physician information, transplant specifics, and required signatures. The form emphasizes the need for supporting statements from specialists, medical evaluations, HIV test results, and compliance with DMAP guidelines. Additionally, it provides contact information for further inquiries.

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Call NJ FamilyCare/Medicaid at 1-800-701-0710 (TTY: 711) to update their contact information. This is especially important if they have moved in the last three years. Watch for mail from the State of New Jersey or your county, and make sure to reply on time to avoid a gap in coverage.

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