Liver Transplant Referral Form

Liver Transplant Referral Form
To begin our assessment the following information is required. Please use the form to ensure ALL REQUIRED documents are received.
Please send patient's records and demographics (including a copy of the insurance card). The required information and financial clearance must be
received before referrals are processed. Please fill out form entirely. Any incomplete or missing information will result in the referral being delayed.
Patient Information
Gender*

MaleFemale
Reason For Referral*

HepatologyLiver CancerLiver Transplant
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Address*
City*
State*
Zip*
SSN*
Phone *
Please enter a valid phone number.
DOB*

MonthDayYear
Age*
Height*
Weight*
Diagnosis*
Required Clinical Information To Process This Referral*

Demographic information (including copy of driver’s license and insurance card)Recent history and physical (dated within the last three (3) months)If Hep C:Last Viral LoadGenotypeIL 28Hepatitis A and B SerologiesAbdominal imaging (ultrasound, CT, or MRI, if available)Specialist consultations pathology reports, operative reportsEGD/colonoscopy results and medication listLast date of alcohol consumptionMELD Labs(CBC, CMP, PT/INR dated within the last three (3) months)AFP Tumor Marker
Referring Physician Information
Referring MD.
Referring Address
Referring City
Referring State
Referring Zip
Referring Fax
Please enter a valid phone number.
Referring Phone
Please enter a valid phone number.
Primary Care Physician Information
PCP
PCP Address
PCP City
PCP State
PCP Zip
PCP Fax
Please enter a valid phone number.
PCP Phone
Please enter a valid phone number.
Primary Insurance
Insurance Co
Insured
Insured DOB

MonthDayYear
Policy #
Group#
Phone #
Please enter a valid phone number.
Secondary Insurance
Secondary Insurance Co
Secondary Insured
Secondary Insured DOB

MonthDayYear
Secondary Policy #
Secondary Group#
Secondary Phone #
Please enter a valid phone number.
PLEASE SEND INFORMATION TO: Tampa General Liver Referral Department
Fax: 813-844-1655
For a referral: 813-844-8686
To speak to a transplant coordinator: 813-844-7137
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