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

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

TRANSPLANT REQUEST FORM FamilyCare ... - FamilyCare, Inc. - familycareinc Preview on Page 1

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4.4 out of 5

35 votes

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 type, medical history, and supporting evidence. The form emphasizes the need for signatures from both the transplant center physician and the referring physician, as well as compliance with specific guidelines and criteria related to transplant eligibility.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the date at the top of the form. Then, fill in your name and contact information in the designated fields.
Provide the member's name, date of birth, and recipient ID number. Ensure accuracy as this information is crucial for processing.
Complete the physician's details including their name, phone number, and fax number. Specify the facility where the transplant will occur.
Indicate the anticipated admission date and length of stay. Fill in relevant ICD-9 and CPT codes for accurate billing.
Document current HIV test results along with their test date. Include any contraindications based on DMAP policies.
Outline any alternative treatments considered and provide reasons for ruling them out. This helps establish a comprehensive treatment history.
Finally, ensure that the transplant center physician signs at the bottom of the form before submission.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is NJ Medicaid the same as NJ FamilyCare?

NJ FamilyCare - New Jerseys publicly funded health insurance program - includes CHIP, Medicaid and Medicaid expansion populations.

Is NJ FamilyCare and Medicaid the same thing?

The NJ FamilyCare program began as Medicaid in the 1960s for very low income people and grew incrementally to include various age/eligibility categories and rules.

How do I request information for NJ FamilyCare?

If you have questions about NJ FamilyCare, including your benefits or the status of an application, please call NJ FamilyCare at 1-800-701-0710 (TTY: 711).

How can I check the status of my NJ FamilyCare application?

If you applied for NJ FamilyCare coverage through the website .njfamilycare.org, or by phone, you can track your applications status by calling 1-800-701-0710. If you applied for NJ FamilyCare coverage through a county welfare office or board of social services, your application still may be in process.