KCOR Provider Referral Form
Thank you for choosing Kidney Care of the Rockies! If you have any questions regarding this referral, please contact your dedicated KCOR liaison.
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
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Month
-
Day
Year
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Patient Phone Number
*
Please provide the patient's preferred phone number that we should call to schedule an appointment.
Referring Provider/Clinic
*
Please provide the name of the Referring Provider and Clinic/Hospital they are associated with.
Reason for Referral:
*
Please include the reason for the patient's referral, i.e. CKD, AKI, HTN, etc.
Is this an urgent or routine referral?
*
Please Select
Urgent (will be seen within 72 hours)
Routine (will be seen within 30 days)
Somewhere in between
Urgent referrals will be seen within 3 business days. If the referral is routine, the patient will be seen within 30 days. If you have a desired time frame in mind, you may enter it below.
What is the preferred time-frame that you want this patient seen?
i.e. "within 2 weeks," "patient needs seen before procedure on 3/10/26," etc.
If the patient lives at a nursing home or assisted living facility, please provide the name of the facility below.
Please provide the name of the nursing home or assisted living that this patient is a current resident of.
If we need to request additional records from your facility, what is the best way for us to obtain those?
*
Please enter your preferred method for us to obtain additional patient records. I.e. fax number, phone number, person of contact, email, etc.
If you are able, please upload a patient demographic sheet and the most recent set of patient lab results.
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