Transplant Checklist Step 1 of 3 33% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Name* First Last Error Message Provider InformationProvider NPI* 10 digitsProvider Name* Error Message Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Clinical InformationType of Request*Type of Request *EvaluationConsultationTransplant ListingRe-CertificationDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Please include all of the following for Evaluation/Consultation All Medical and Behavioral Health Diagnosis Progress notes including disease progression and current status (Acute/Chronic, remission, etc) MELD/PELD score (Liver only) Please include the following for the Transplant Listing and Re-Certification All Medical and Behavioral Diagnoses Progress notes including disease progression and current status (acute, chronic, remission, etc.) Please include height and weight or BMI MELD/PELD score (Liver only) Listing Status Prior Transplant History Facility protocol/criteria Test Results Availability of donor (if applicable) Behavioral health and Social Worker Evaluations and protocols completed within the last year Documentation of member adherence to medical, behavioral health and substance abuse appointments and treatment plans Consults and all other evaluations Facility’s smoking cessation protocol, documentation of member’s adherence to the protocol Psycho-Social Support Network Dental Evaluation attached (Mandatory for Bone Marrow Transplants) Attach Clinical Information* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 3. Attach only PDF and Word filesSignature of Treating Physician*Signature Date* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Attach only PDF and Word filesSignature of Physician or Licensed Provider*Signature Date* Comments Authorization is not a guarantee of payment CAPTCHA