For more information, please call Guest Services at 1-800-244-0680

Dialysis Treatment Request

For Dialysis Treatment within the next 7 days, please call 1-800-244-0680 otherwise, please complete this form in its entirety. Please have your destination address and or zip code available before you begin. This information is required in order to find the closest available facility to your destination.

IMPORTANT for Peritoneal Dialysis Patients :

For Peritoneal Dialysis (PD) Patients wishing to travel and looking for a back-up facility please call 1-800-244-0680.

Thank you!

All fields are required unless marked "optional."

Section: 1 of 6
Travel Information
Type of Placement:

Arrival Date:		MM/DD/YYYY
Departure Date:		MM/DD/YYYY
First Requested Treatment Date:	*	MM/DD/YYYY
Last Treatment Date:		MM/DD/YYYY
Total Number of Treatments:		Numeric ONLY
	* For placement within the next 7 days, please call 1-800-244-0680. This form requires a minimum of 7 days notice.
Purpose of Travel:

Destination Street:		(optional)
Destination City:
Destination State:
Destination Zip Code:
Phone Number:		(optional) (___)___-____

Distance Willing to Travel to Facility:

Section: 2 of 6
Your Information
Is this Placement Request for a DaVita Patient?	Yes No
E-mail:

Section: 3 of 6
Patient Information

Patient First Name:
Patient Middle Initial:	(optional)
Patient Last Name:

Patient Date of Birth:
Patient ZIP Code:
Patient Phone Number:		(___)___-____
Patient E-mail:		(optional)

Section: 4 of 6
Patient Home Facility Information
Home Facility Name:
Home Facility City:
Home Facility State:
Home Facility Phone Number:		(___)___-____
Fax:		(___)___-____

Home Social Worker Name/Representative Name:

Section: 5 of 6
Treatment Information
Access Type:

Treatment Schedule:
Is Your Treatment Schedule Flexible?
Does Patient Require Isolation?
Length of Treatment:	:	(hours : minutes)

Primary Insurance Type:
Name of Primary Insurance Company:
Name of Secondary Insurance Company:		(optional)

Section: 6 of 6
Additional Information
Additional Information or Special Handling:		(optional)

This site is for informational purposes only and is not intended to be a substitute for medical advice from a physician. Please check with a physician if you need a diagnosis and/or for treatments as well as information regarding your specific condition. If you are experiencing urgent medical conditions, call 9-1-1

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Dialysis Treatment Request

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