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 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Referring Physician Information section. Enter your name, office address, UPIN/NPI number, and contact details accurately.
3. Next, complete the Patient Information section. Provide the patient's full name, date of birth, address, and contact numbers.
4. 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.
5. Proceed to Medical Information. Clearly list the primary and secondary diagnoses along with any allergies. Attach necessary medical documents as specified.
6. Indicate if the patient is on dialysis and provide relevant details about their treatment schedule and external dialysis center.
7. Finally, review all entered information for accuracy before submitting via fax to (480) 342-0555.

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