Refer a Patient: Liver Transplant Fremont

To schedule a liver transplant evaluation, we require the forms, imaging tests and medical reports listed below. Please note that if we do not receive the requested items within two weeks, or after three requests, we will cancel the referral.

Requests for lab work, medical reports and imaging studies cover the last six months only (except for HCC patients, as described below).

Please gather the following:

• UCSF liver referral form. Download our referral form PDF and complete it. If the patient’s liver disease is due to alcohol, please include the date of their last drink. (The patient must have six months of sobriety to be considered for transplant evaluation.)
• Most recent health history and physical exam. Include the cause of liver disease.
• Most recent abdominal imaging study. This may include MRI, CT or ultrasound studies.
• Other studies. Include any other studies performed, such as cardiac records (ECG, echo, stress test, cath), PFT, ABG, EGD, colonoscopy or liver biopsy.
• Most recent lab work. Include MELD-sodium labs (albumin, total bilirubin, creatinine, sodium, INR). The MELD-sodium score (MELD-Na), used to determine priority in patient referral, should be calculated and included on referral form. If your patient's MELD-sodium score (MELD-Na) is greater than 25, call us at the number below and ask to speak with the transplant evaluation nurse coordinator.
• Insurance authorization request. Download this list of CPT codes to request an authorization for liver transplant evaluation at UCSF Health. Please call us if you have questions.
• Insurance information. Include a copy of the patient's insurance card (both sides).
• Patient's demographic and contact information. Please provide this on both our referral form (see above) and on a separate sheet of paper with the heading "Demographic and Contact Information."

Primary liver cancer (HCC) referrals

Please gather the following for HCC patients:

• Abdominal CT or MRI reports. Include the report showing when HCC was first diagnosed, as well as all reports since the diagnosis.
• Imaging CD. This should contain 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 performed, please submit reports for chemoembolization, radiofrequency ablation (RFA), recent chest CT, recent AFP study, and so on.