Dialysis Patient Travel Request Form

A minimum 30 days notice is required. Once your request is received, a facility representative will contact you for additional information. Patient Name  *Patient Email  *Date(s) of Request  *Date Returning to Home Unit  *Name of Unit(s)  *Phone Number  *Are you willing to accept any unit?  *Are you willing to accept a different city?  *

Complete if treatment is needed at more than one unit during your trip:

Second Unit City State Zip Code 

Local address and phone number. (Where you will be staying.)

Address  *Phone  *Please be aware that changes in travel arrangements after being accepted are the responsibility of the patient. If patient does not have secondary insurance or if insurance is not accepted by visiting unit, patient may be responsible for payment in advance.