INTEGRIS Health Kidney and Pancreas Transplant

Phone

405-949-3816
1-888-949-3816

Address

3400 N.W. Expressway
Building C, Suite 700
Oklahoma City, OK 73112
GET DIRECTIONS

Kidney and Pancreas Self Referral Form

* Required fields

* Marital Status
* Gender
* Have there been any non-compliance concerns in the last 3 months?
* Is this referral for:
* Does patient have Indian Health Services?
* Is the patient on dialysis?
Type

Upon completion of this form, please fax the following documents to 405-815-6404: CMS 2728, drivers license, social security card, insurance card(s), history and physical from your nephrologist.