Please use this form to submit a referral to INTERLINK Health Services Inc. for a potential organ transplant. Fill out the form completely and click "Submit" to immediately send your referral to INTERLINK. If you prefer to print a copy of this form and fax it to INTERLINK with referral information, please click on the link at the bottom of this page to be taken to the PDF Notice of Potential Transplant Form.

 

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.

 

Contact Information
Name
E-Mail Address
Street Address
City, State, Zip
Company Name
Contact Phone
Contact Fax

 

Patient Information
Patient Name
Insured ID#
Date of Birth
Sex
Male
Female
Patient Residence Address, Street, City, State
Employer Group Name
Employer Group City, State

 

Benefit Coverage
Health Plan Coverage Primary
Yes
No
Medicare Advantage Plan
Yes
No
Type of Plan
Fully Insured
Self Insured
Employer Group Renewal Date

 

Transplant Information
Type
Adult
Pediatric
Organ Source
Cadaveric Donor
Living Donor
ICD-9 Code
Diagnosis
Evaluation Date

 

Transplant Facility Information
Facility Name
City, State

 

Case Management Information
Check here if same as Contact Information
Company
City State
Case Manager
Phone Number
Email

 

Reinsurer or MGU Information
Check here if same as Contact Information
Reinsurer or MGU
Reinsurer
MGU
Company
City, State
Contact Name
Phone Number
Email

 

Claims Payment Information
Check here if same as Contact Information
Company
Street Address
City, State, Zip
Claims Contact Name
Phone Number
Fax Number
Email

 

Candidate Education Booklet
Send Candidate Education Booklet
Yes
No

Booklet will be sent to the case manager for distribution to the patient

 
Source Tracking Number
Additional Comments

 

 

 

 

 

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All Rights Reserved.