Nephrology Referral Form

NKDEP encourages collaborative management and communication between primary care providers (PCPs) and nephrologists to help improve patient outcomes.

The interactive Nephrology Referral Form is designed to help referring PCPs share important patient data with the consulting nephrologist. The form can be saved to a computer, edited, and shared electronically with the nephrologist.

The form provides fields for entering data that are likely to be useful for patient evaluation. These include: reason for referral, diabetes status, urine and blood test results, blood pressure readings, current medications, and others. Learn more about why certain data are included.

Remember to save the form to your computer before entering data. Also, to comply with the Health Insurance Portability and Accountability Act of 2002, please protect the personal health information contained in the completed form.