INTERLINK Health Services - Notice of Potential Transplant Form

Please use this form to submit a referral to INTERLINK for a potential organ transplant. By completing each requested field and clicking on "Review" at the bottom of the page, you will be taken to page where you can review the information you provided and print a copy for your records. From that page, you can click "Submit" to immediately send your referral to INTERLINK.

NOTE: INTERLINK will provide the financial terms of an in-network facility to you within 48 hours of referral receipt. To help us continue to process your referral in a timely manner, please provide all requested information.


Source Tracking Number

Contact Information
Name
E-Mail Address
Company Name
Contact Phone
Contact Fax
Patient Information
Patient Name
Insured ID#
Date of Birth
Sex	Male Female
Patient Residence City, State
Employer Group Name
Employer Group City, State
Benefit Coverage
Health Plan Coverage Primary	Yes No
Employer Group Renewal Date
Transplant Maximum Coverage
Organ and/or Donor Limitations
Transplant Information
Type
Organ Source	Cadaveric Donor Living Donor
ICD-9 Code
Diagnosis
Transplant Facility Information
Facility Name
City, State
Evaluation Date
Case Management Information
Company
City State
Case Manager
Phone Number
Email
Reinsurer Information
Company
City, State
Contact Name
Phone Number
Email
Claims Payment Information
Company
Street Address
City, State, Zip
Claims Contact Name
Phone Number
Fax Number
Email
Candidate Education Booklet
Send Candidate Education Booklet Yes No
Additional Comments

If you prefer to print a copy of this form and fax it to INTERLINK with referral information, please click on the link below to be taken to the PDF Notice of Potential Transplant Form.

View Form in PDF Format

Thank you for choosing INTERLINK Health Services for your

transplant network needs!