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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Referring Physician Information section. Enter your name, office address, UPIN/NPI number, and contact details accurately.
Next, complete the Patient Information section. Provide the patient's full name, date of birth, address, and contact numbers.
In the Other Contacts section, include insurance details for both primary and secondary providers. Ensure to fax a photocopy of the insurance card as required.
Proceed to Medical Information. Clearly list the primary and secondary diagnoses along with any allergies. Attach necessary medical documents as specified.
Indicate if the patient is on dialysis and provide relevant details about their treatment schedule and external dialysis center.
Finally, review all entered information for accuracy before submitting via fax to (480) 342-0555.

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See more Referring a Patient to Kidney/Pancreas Transplantation Program at Mayo Clinic - MCS7657-03. Referring Patient Kidney/Pancreas Transplantation Program Clinic - Referring Patient Kidney Pancreas Transplantation Program Clinic fax form 480 versions

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What is the ICD 10 code for combined kidney and pancreas transplant?

ICD-10-CM Z94. 0 is grouped within Diagnostic Related Group(s) (MS-DRG v42.0): 008 Simultaneous pancreas and kidney transplant. 019 Simultaneous pancreas and kidney transplant with hemodialysis.

What is the ICD-10 code for Z85 79?

8 - Other transplanted organ and tissue status.

How do I refer a patient to Mayo Clinic?

You can call us at 1-855-392-8400 to confirm necessary information for the referral, and route your request and records to the appropriate department for review.

What is the ICD-10 code for kidney and pancreas transplant?

A kidney-pancreas transplant is an operation to place both a kidney and a pancreas at the same time into someone who has kidney failure related to type 1 diabetes. In many cases, both transplanted organs may come from one deceased donor.

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