University of California San Francisco

Liver Transplant Evaluation Referral

Overview

For us to schedule an appointment for your patient, we need the following:
  1. Required Forms
  2. Required Tests and Studies
  3. Required Medical Reports
Please Note: Requests for lab work, medical reports, and imaging studies cover only the period of the last 6 months (except for HCC patients as described in the special instructions below).

Steps for Completing Forms and Gathering Documents

Please Note: Clicking on any link to a form below will open it in a new browser tab.  This prevents work being lost by inadvertantly hitting the back button.

  • Please complete the UCSF Liver Referral Form (this is an interactive PDF which can be filled out from within a web browser and then printed.)
  • Patient's most recent History and Physical Examination (H&P) or clinic note, which must include the cause of liver disease (i.e., alcohol, Hepatitis C, etc.)
    • Please provide the date of patient’s last drink on the UCSF Liver Referral Form.
    • Patient must have 6 months sobriety to be considered for transplant evaluation
  • Most recent abdominal imaging study (MRI, CT, and/or ultrasound)
    • Other studies (if already performed): cardiac records (ECG, echo, stress test, cath), PFTs, ABGs, 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 of patient referral, should be calculated and included on referral form. 
    • If your patient's MELD-sodium Score (MELD-Na) is greater than 25, please call our Transplant Evaluation Nurse Coordinator at: (415) 353-1888
  •  Liver Transplant Evaluation Insurance Authorization Request
    • Obtain authorization to expedite patient’s appointment.
    • For financial questions, please call 415-353-1888.
  • Patient’s insurance information. Please include a copy of patient's insurance card (both sides)
  • Patient’s demographic and contact information
    • Please provide this information on BOTH:
      1) The UCSF Liver Referral Form (see above) AND
      2) A separate sheet of paper with a heading "Demographic and Contact Information"

Special Instructions for Patients with Primary Liver Cancer (HCC)

Please include the following for HCC Patients:
  • Adominal CT or MRI Report 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:
    • The most recent abdominal imaging study (CT or MRI only - not ultrasound) AND
    • The initial CT or MRI on which HCC was first diagnosed.
  • Other study and treatment reports (if already performed): Chemoembolization, Radio Frequency Ablation (RFA), etc., Recent chest CT report, and recent AFP study.
IMPORTANT:  We will not schedule a liver transplant evaluation until all the requested information has been received.  If we have not received this information within two (2) weeks or after three requests, we will cancel the referral.

How to Fax the Requested Forms and Documents

Please fax the documents below in the order shown (1-7) to: (415) 353-2102 - Attn: UCSF New Liver Referrals

  1. Liver Transplant Evaluation Fax Cover Sheet and Checklist - Please check each box after ensuring all the required paperwork is ready for submission.
  2. UCSF Liver Referral Form
  3. Liver Transplant Evaluation Insurance Authorization Request
    Please print out the following cover sheets and followed by the applicable documents and reports. 
  4. SECTION 1 - Consultations / Clinic Visits 
  5. SECTION 2 - Procedures 
  6. SECTION 3 - Labs
  7. SECTION 4 - Demographics and Insurance
     

CDs/DVDs of Imaging Studies

CDs/DVDs of CT/MRI/PET and similar studies should be sent to the following address:

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

Questions

Please call (415) 353-1888 - Option 0