Methodist Dallas Medical Center Recipient Application for Organ Transplant
Application for (check all organs that apply):
Kidney
Pancreas
Liver/Kidney
Possible donor sources:
Living Related
Living Unrelated
Deceased Donor
Paired Donor Exchange
Who referred you to Methodist?
Physician
Insurance
Self
Other
Primary diagnosis
(example: diabetes, FSGS, hypertension)
PHYSICIAN AND DIALYSIS CENTER INFORMATION
Please let your social worker make a copy of this application
Are you currently on dialysis?
Yes
No
Type of dialysis (check one)
Home Hemo
PD
In-Center Hemo
Date Current Dialysis Began
-
Month
-
Day
Year
Date
Dialysis Shift
Mon Wed Fri
Tues Thurs Sat
Shift
1
2
3
4
Nocturnal
Dialysis Center, leave blank if you are not on dialysis
Name
Dialysis Center Address, leave blank if you are not on dialysis
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is your Kidney Doctor?
Name
Kidney Doctor's Phone Number
-
Area Code
Phone Number
Kidney Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is your Primary Care Physician?
Name
Primary Care Physician's Phone Number
-
Area Code
Phone Number
Primary Care Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PATIENT INFORMATION
Patient Name
*
First Name
Middle Name
Last Name
(Maiden)
SS#
Social Security #
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Mobile Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
DOB
*
-
Month
-
Day
Year
Date of Birth
Age
Sex
Male
Female
N/A
Religion
Race
Marital Status
Single
Married
Separated
Divorced
Widowed
Patient's Employer
Employer
Work Phone Number
-
Area Code
Phone Number
Work Status
Full-time
Part-time
Retired
Disabled
Is patient a U.S. Citizen?
Yes
No
If "no," what country?
Country of Citizenship
Does patient speak English?
Yes
No
If “no,” what language?
Language(s) Spoken, non-English
SPOUSE OR PARENT (IF MINOR) INFORMATION
Name
First Name
Last Name
SS#
Social Security #
Relationship to Patient
Employer
Work Phone Number
-
Area Code
Phone Number
Alternate Contact Person
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation to Patient
INSURANCE INFORMATION
MEDICARE I.D.
If Applicable
Effective Date
-
Month
-
Day
Year
Date
Medicare Due to (Check One)
Kidney disease
Age
Social Security Disability
Medicaid I.D.
Effective Date
-
Month
-
Day
Year
Date
*Texas Residents Only- Texas Kidney Healthcare I.D.
INSURANCE COMPANY ONE
If Applicable
Insurance Type
HMO
PPO
POS
Indemnity
Effective Date
-
Month
-
Day
Year
Date
Insurance Company Name
Name of Group/Employer
Group #
Policy #
Insurance Benefits Phone number
-
Area Code
Phone Number
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Insured Person
First Name
Last Name
Relationship to Patient
Date of Birth of Insured
-
Month
-
Day
Year
Date of Birth
SS# of Insured
Social Security #
Other I.D. Number
INSURANCE COMPANY TWO
If Applicable
Insurance Type
HMO
PPO
POS
Indemnity
Effective Date
-
Month
-
Day
Year
Date
Insurance Company Name
Name of Group/Employer
Group #
Policy #
Insurance Benefits Phone number
-
Area Code
Phone Number
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Insured Person
First Name
Last Name
Relationship to Patient
Date of Birth of Insured
-
Month
-
Day
Year
Date of Birth
SS# of Insured
Social Security #
Other I.D. Number
Transplant Center
Are you currently listed at another transplant center?
Yes
No
Transplant Center
Transplant Center Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
Transplant Center Phone Number
-
Area Code
Phone Number
PREVIOUS TRANSPLANT
If Applicable
Previous organ transplant?
Yes
No
Organ Transplanted
Date of Transplant
-
Month
-
Day
Year
Date
Transplant Hospital
Signature
*
Submit
Should be Empty: