Refer a Patient: Liver Transplant Program

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To schedule an appointment for your patient, we need these items:

• Required forms
• Required tests and studies
• Required medical reports

Please note: Requests for lab work, medical reports and imaging studies cover only the last six months (except for HCC patients, as described in the special instructions below).

IMPORTANT: We will not schedule a liver transplant evaluation until all the information requested below has been received. If we haven't received it within two weeks or after three requests, we will cancel the referral.

1. Gather required documents

Completed UCSF Liver Referral Form (a PDF that can be filled out in your browser and then printed)

• Include the date of the patient's last drink. (Patient must have six months of sobriety to be considered for transplant evaluation.)

  Download referral form

Most recent H&P (history and physical exam) or clinic note

• Must include the cause of liver disease (e.g., alcohol, hepatitis C).

Most recent abdominal imaging study

• MRI, CT or ultrasound

Other studies, if already performed

• Cardiac records (ECG, echo, stress test, cath), PFT, ABG, EGD, colonoscopy, liver biopsy

Most recent lab work, including MELD-sodium labs (albumin, total bilirubin, creatinine, sodium, INR)

• The MELD-sodium score (MELD-Na), used to determine priority in patient referral, should be calculated and included on referral form.
• If your patient's MELD-sodium score (MELD-Na) is greater than 25, call our Transplant Evaluation Nurse Coordinator at (415) 353-1888.

Liver Transplant Evaluation Insurance Authorization Request

• Download and complete this form to expedite patient's appointment:

  Download authorization form

• For financial questions, call (415) 353-1888.

Insurance information

• Include a copy of patient's insurance card (both sides).

Patient's demographic and contact information

• Please provide this on BOTH 1) The UCSF Liver Referral Form (see above) AND 2) a separate sheet of paper with the heading "Demographic and Contact Information."

Special Instructions for Patients With Primary Liver Cancer (HCC)

Include the following for HCC patients:

• Abdominal CT or MRI report showing when HCC was FIRST DIAGNOSED (required for listing the patient)
• All abdominal CT and MRI reports since the HCC diagnosis (also required for listing and review)
• A CD that includes BOTH 1) the most recent abdominal imaging study (CT or MRI only, not ultrasound) AND 2) the initial CT or MRI on which HCC was first diagnosed
• Other study and treatment reports (if already performed): Chemoembolization, radiofrequency ablation (RFA), recent chest CT report, recent AFP study, and so on

2. Fax these items

Please fax the seven items below in the order shown to (415) 353-2102. Write "Attn: UCSF New Liver Referrals" on the cover sheet.

1. Liver Transplant Evaluation Fax Cover Sheet and Checklist: Check each box after making sure all required paperwork is ready for submission.
2. UCSF Liver Referral Form
3. Liver Transplant Evaluation Insurance Authorization Request



Print out the following four cover sheets and place them with the appropriate documents and reports:

4. SECTION 1 - Consultations/Clinic Visits
5. SECTION 2 - Procedures
6. SECTION 3 - Labs
7. SECTION 4 - Demographics and Insurance

3. Mail imaging studies

Send CDs/DVDs of CT, MRI, PET and similar studies by postal mail.

Mail

UCSF Liver Transplant Program
Attn: New Referrals
350 Parnassus Ave., Suite 805
San Francisco, CA 94117