Patient Referral Form

  • Mālama Kidney Center serves as an extension of physicians and their practice to provide education, support, and care coordination for patients with CKD stages 3a-5. We believe that patient exposure to intensive preventative education can significantly decrease the complications associated with dialysis initiation and slow the progression to ESRD.

    Our Services Include:

    • Health Education: Tailored kidney education with an APRN and Care Manager.
    • Nutrition Therapy: One-on-one medical nutrition therapy with a Registered Dietitian.
    • Care Management: Care coordination and health coaching
    • Behavioral Health: Psychosocial support provided by a Licensed Social Worker

    For any questions, feel free to call us at (808) 953-2502 or email aloha@malamakidney.com.

     

    SELECT 'NEXT' TO CONTINUE MAKING A REFERRAL

  • Patient Referral Form

    Care management, patient education, and medical nutrition therapy for patients with Chronic Kidney Disease.

  • Provider Information

  • Date*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient Demographics

  • Gender
  • Format: (000) 000-0000.
  • Phone Type
  • Interpreter Needed?

  • Insurance Information

  • Select all that apply*

  • Referral Reason

  • Select all that apply*
  • Current CKD Stage (3a - 5)*
  • Patient has a Nephrologist?*
  • 0/50

  • Please fax the documents listed below to (808) 913-3843:

    • Demographics, ID/Insurance Card, and Clinical Profile
    • PCP Consult Note and/or Discharge Summary
    • Labs (include most recent eGFR and serum creatinine values)
    • Medication List
    • Last Progress Note with Medication List
    • Renal imaging results if available (US/CT)
  •  
  • Should be Empty: