The Temporary Care Of Dialysis Patients (Transients)

Guidelines for Transient Hemo-Dialysis Patience Acceptance

  1. Patients cannot be considered in our unit, until the required information has been received and reviewed by our Medical Director and the Head Nurse. When travel is anticipated, it is advisable to have the home unit forward all requested information, as soon as possible. A minimum of 21 days notice is recommended.
  2. After all of your records have been reviewed, if we can medically accommodate you, we will inform you in writing, your treatment schedule will be included in this notice. Once accepted, we will also notify you of your financial responsibility.
  3. Medicare participants, that do not have a secondary insurer, are required to pay 20% of their treatment charge, plus 20% for any drugs administered. If you have a secondary insurance, which has been verified for coverage, no monies will be required at the time of your treatment.
  4. Visitors are requested not to come into the dialysis area. We have a lobby where family members or friends may wait.
  5. Smoking is not allowed in our facility.
  6. We must receive all requested information as soon as possible. Delay in receipt of all or part of the information requested, could result in non-acceptance into our facility. Please sign and have you facility return this form with your requested information.

 

  
 

Patient Acceptance Form

Please sign and return this form with the requested information.

 

Transient Hemo-Dialysis Division Form

Please sign and return this form with the requested information.

 
Transient Patient Transfer Checklist

Name:______________________________________________________

(PRINT)

Before being accepted as a transient patient at HealthQuest, the following information is needed:

______ Transient Dialysis Information Summary Sheet

______ Medical History and Physical Examination (within one year)

______ Short Term Care Plan

______ Long Term Care Plan

______ MEDICAL CONDITION: STABLE

______ Copy of last Clinic visit

______ INSURANCE CARDS AND MEDICARE CARD (COPIES)

______ Nursing Assessment

______ Social Worker Assessment – Social History

______ Dietician Assessment – Diet History

______ Medication Summary

______ Labs – cbc, chemistry profile summary

______ Hepatitis B surface antigen (current)

______ EKG (current)

______ Chest xray (current)

 

  
 

 

  

 

 

 

 

 

 

 

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