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UPMC Heart Transplant Program Personal Data Sheet - UPMC.com

UPMC Heart Transplant Program Personal Data Sheet - UPMC.com 2026

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The document is a personal data sheet for the UPMC Heart Transplant Program, requiring patients to provide comprehensive information for processing their application. It outlines the necessary patient and physician details, insurance information, and medical history required for evaluation as a heart transplant candidate. The document emphasizes the importance of completing all fields to expedite the financial clearance and scheduling process, which may take 2-4 weeks.

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Click ‘Get Form’ to open the UPMC Heart Transplant Program Personal Data Sheet in our editor.
Begin by filling out the 'Patient Information' section. Enter your name, date of birth, gender, race, and ethnicity. Ensure all fields are completed for efficient processing.
Next, provide details in the 'Referring Physician Information' section. Include the physician's name, address, phone number, and fax number.
In the 'Insurance Information' section, indicate your employment status and provide your primary insurance details. Remember to attach copies of both sides of your insurance card for clarity.
Complete the 'Emergency Contact' information by entering their name, relationship to you, and contact details.
Finally, ensure you attach all required medical documents as specified at the end of the form before submitting it via fax to expedite processing.

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2016	4.8 Satisfied (171 Votes)

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

What ejection fraction is considered a disability for heart failure?

To qualify for SSDI, the percentage of blood pumped out of the heart with each heartbeat, which is referred to as the hearts ejection fracture, must be 30 percent or less or the hearts left ventricular end-diastolic dimensions must be larger than 6.0 cm.

What is status 2 on the heart transplant list?

Heart Transplant Status Levels Status 1: Critically ill and on mechanical support. Status 2: In the hospital on mechanical support or with severe ventricular arrhythmias. Status 3: In the hospital and having complications with a ventricular assist device (VAD)

What ejection fraction qualifies for transplant?

A healthy persons ejection fractions are at 50 or 60%. As bad as his condition was, Derek didnt meet the requirements for a heart transplant, which mandates an ejection fraction of 17% or lower.

What ejection fraction requires a heart transplant?

This percentage is called the ejection fraction. You may have been told that your heart is working at some percentage of normal, and your doctor was probably referring to the ejection fraction. To be considered for transplant, the percentage is usually less than 20%.

At what point is a heart transplant needed?

You may need a heart transplant if your heart is failing and other treatments are not effective. End-stage heart failure is the final stage of heart failure. The heart muscle is failing severely in its attempt to pump blood through the body. Other treatments are no longer working.

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Who gets priority for a heart transplant?

Patients who are categorized as Status 1 and 2 have top priority in receiving heart transplants. They are often severely ill, may be on advanced life support, and are not expected to survive more than a month. For these reasons, they will be offered an available heart first.

What disqualifies you from being on the heart transplant list?

Contraindications Major systemic disease. Age inappropriateness (70 years of age) Cancer in the last 5 years except localized skin (not melanoma) or stage I or prostate. Active smoker (less than 6 months since quitting) Active substance abuse. HIV. Severe local or systemic infection. Severe neurologic deficits.

What is the ejection fraction cut off for heart failure?

40% to 49% is mid-range ejection fraction: The hearts pumping ability is slightly below normal. You might not experience heart failure symptoms. Or, you may have symptoms with physical activity but not at rest. 39% or less is heart failure with reduced ejection fraction (HFrEF): Pumping ability is below normal.

UPMC Heart Transplant Program Personal Data Sheet - UPMC.com 2026

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How to use or fill out UPMC Heart Transplant Program Personal Data Sheet - UPMC.com with DocHub

See more UPMC Heart Transplant Program Personal Data Sheet - UPMC.com versions

Complete this form in 5 minutes or less

Got questions?

What ejection fraction is considered a disability for heart failure?

What is status 2 on the heart transplant list?

What ejection fraction qualifies for transplant?

What ejection fraction requires a heart transplant?

At what point is a heart transplant needed?

Security and compliance

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People also ask

Who gets priority for a heart transplant?

What disqualifies you from being on the heart transplant list?

What is the ejection fraction cut off for heart failure?

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