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Required Medical Records

• Face Sheet
• History & Physical
• Hepatitis B Panel
  All three items required:
  1. Hep B Surface Antigen (HBsAg) within 30 days
  2. Hep B Surface Antibody (HBsAb) within 12 months
  3. Hep B Total Core Antibody (HBcAb) within 12 months
• Tuberculosis Test
  One of the following within 90 days:
  • Purified Protein Derivative (PPD)
  • Chest X-Ray (CXR)
  • QuantiFERON-TB Gold (QFT-G)
  • T-SPOT
  • Mantoux Tuberculin Skin test (TST)
• Texas, South Carolina and Arizona
  

  The states of Texas, South Carolina and Arizona require all standard records, as well as the additional items below.

  • Additional requirements for Texas:
    1. Pre-Dialysis Labs
    2. Medication & Allergy List
  • Additional requirements for South Carolina:
    1. Entire Hep B panel must be drawn within 30 days
  • Additional requirements for Arizona:
    1. History & Physical is within 30 days
    2. Medication & Allergy List

Protocols for Active TB or Hepatitis B

Tuberculosis (TB)

Patients contagious for tuberculosis (TB) are unfortunately not able to dialyze in an outpatient setting.

Certain cases of latent TB can be accepted with coordination of ������Ƶ����app����, the local jurisdictional public health department and the attending nephrologist. Before returning to an outpatient setting, any patient receiving treatment for active pulmonary TB disease is to have completed a minimum of one week of the appropriate tuberculosis therapy and:

• Demonstrate three consecutive negative sputum smears for acid fast bacilli (AFB) that have been collected at least eight to 24 hours apart
• Be cleared for return to the outpatient setting by the local jurisdictional public health department and attending nephrologist
• Will be instructed regarding the importance of taking the anti-tuberculosis therapy as described

Hepatitis B (Hep B)

Patients contagious with Hepatitis B must receive isolation treatment. ������Ƶ����app���� has facilities across the country that offer isolation treatment. Search for “isolation facilities” via the ������Ƶ����app���� Placement Portal or contact ������Ƶ����app���� Admissions directly at 1-866-475-7757.

Transportation

������Ƶ����app���� does not provide transportation to or from our dialysis centers. Please use local resources to coordinate patient transportation.

Placement Considerations

Financial Clearance

Patient must have financial clearance, meaning they have insurance coverage or an appropriate path to get coverage for outpatient dialysis treatments at ������Ƶ����app����. If patient has no insurance and no path to insurability, a Single Patient Agreement (SPA) or Multi Patient Agreement (MPA) is required. Admissions can verify a patient’s insurance policy once the placement request is received.

Please fill out the insurability tile within the ������Ƶ����app����® Placement Portal as soon as possible, or send a completed Insurability Questionnaire to ������Ƶ����app���� as soon as possible.

������Ƶ����app���� may be required to comply with state or municipality-specific charity care requirements in certain jurisdictions. For more information regarding the applicability of charity care, please contact ������Ƶ����app���� Guest Services.

Out-Of-Network (OON)

If a patient's insurance is considered OON, ������Ƶ����app���� must engage with the patient's insurance payor to secure an authorization. Unfortunately, ������Ƶ����app���� cannot speed up their determinations. However, the quicker we receive a referral, the sooner we can submit an authorization request.

Veterans Affairs (VA)

All patients using VA benefits will require an authorization from the VA. Referral sources will need to notify the VA of the patient's need for outpatient treatment and start the authorization process.

Single Patient Agreement (SPA)

If patient has no insurance and no path to insurability, a Single Patient Agreement (SPA) or Multi Patient Agreement (MPA) is required. Referral sources can work directly with their Admissions Specialist to resolve.

High Acuity (HASTE)

������Ƶ����app���� conducts a thorough review of every patient to enable them to receive the best care possible. Patients of a higher acuity require additional review to help support their safety.

Please fill out the High Acuity tile within the ������Ƶ����app���� Placement Portal or send a completed High Acuity Questionnaire to ������Ƶ����app���� as soon as possible if a patient falls into one of the following categories:

• Unable to treat in a dialysis chair (bed-dependent)
• Inotropic infusions
• LVAD
• Morbidly obese > 450 lbs.
• PEG tube
• Tracheostomy
• Vent-dependent
• Chest tube