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Referral Form

Please use this form to submit a referral to INTERLINK® COE Networks & Programs for a transplant. Fill out the form completely and 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.

Contact Information
Name:
Company:
Street Address:
City, State, Zip:
Email:
Phone:
Fax:
Patient Information
Patient First Name:
Patient Last Name:
Patient Residence Street Address:
City, State, Zip:
Employer Group Name:
Employer Group City, State:
Insured ID:
Date of Birth:
Sex
Benefit Coverage
Health Plan Coverage Primary:
Medicare Advantage Plan:
Medicaid Plan
Type of Plan:
Carve Out:
Employer Group Renewal Date:
Transplant Information
Type:
If Other or Multi Organ:
Age:
Organ Source:
ICD-9 Code:
Diagnosis:
Evaluation Date:
Transplant Facility Information
Facility:
City, State:
Case Management Information
Check here if same as Contact Information
Case Manager:
Company:
Street Address:
City, State, Zip:
Phone:
Email:
Reinsurer or MGU Information
Check here if same as Contact Information
Reinsurer:
Company:
City, State:
Contact:
Phone:
Email:
Claims Payment Information
Check here if same as Contact Information
Company:
Contact:
Street Address:
City, State, Zip:
Phone:
Fax:
Email:
Candidate Education Booklet
Send Booklet (Will be sent to the case manager for distribution to the patient):
Additional Comments/Special Instructions: