Patient Travel Request Form

 Patient Travel Planning.

This packet has been put together to help you arrange for “visitor” dialysis while you are  away on vacation. You need to begin making arrangements at least THREE WEEKS in advance of your trip. Depending on where you are traveling and the time of year (major holidays for example) you may need to begin arrangements even sooner. The staff will make every effort to assist you if you need help. Because “visitor” arrangements are dependent on many factors, particularly availability of dialysis time at the “away’ unit, financial arrangements, etc., you need to be aware of your responsibilities for planning in advance. The Staff will assist you during this process.

Please read all of the following information before beginning your travel plans.

What You Will Need to Do:

When you have the specific date(s) of your travel in mind, please provide local address and phone number and requested days and time of your preferred dialysis appointment.

Please be aware that Medicare is accepted anywhere in the U.S., but remember, unless you have a secondary policy after Medicare, you may be required to pay in advance what Medicare does not cover. (Medicare covers 80% of the cost of your dialysis). Some HMO plans will not cover outside of their covered area. Most HMOs require pre-authorization prior to travel. Be certain you know in advance if your HMO plan will cover and what pre-authorization is required. You can contact the social worker for more information on this if you are not certain.

Almost all units will require the following:

A copy of a Medical History and Physical completed within one year of the travel date. If you have not had a recent physical, be sure that you get one in advance.

A copy of an EKG completed within the past year. Be sure you have this done.

A Chest X-ray or TB Test completed within the past year.

Copies of a recent Hepatitis Test. These are usually done routinely by the unit.

Copies of signed consent and results of an HIV test  prior to travel date. You may need to request that this be done in advance of your travel.

If you are uncertain as to how to arrange the above-mentioned tests, please check with the supervising RN.

If you have questions about any of these steps, please notify the Social Worker. The staff will make every effort to assist with your travel plans, but due to time and other obligations, we may not be able to drop everything for last minute travel, so please plan ahead and have a great trip!

if, for any reason you cannot take your trip as planned, please call the unit you made arrangements with and cancel your reservation. You also need to notify our unit.

Travel Request Form

From:


I am planning a trip and will be dialyizing at another facility on the following dates:
Date From:


Date To:


I am travelling to:
Country:


Visiting Address:


Email:


Phone:


Contact Phone:


Contact Person:


 I realize that if my plans change, it is my responsibility to notify you and the center that I am planning to visit.
 I understand that if I fail to do this, I may not be able to have a treatment at either center at the desired time.
 I have read the Patient Travel Planning Packet and have signed the attached Patient Consent to Release of Medical Information.
Please have the necessary copies of my medical records forwarded to the unit I have made arrangements with.
Thank you,
Signature: