DIALYSIS REFERRAL
Central Dialysis Admissions
Phone: (602) 351-3003/(800) 494-7722
Fax: (833) 804-8618
Monday - Friday 7:00 a.m. to 6:00 p.m.
PATIENT INFORMATION
*Patient Last
*Patient First
MI:
*Patient Phone (daytime)
Phone (evening)
*Birth Date
*Insurance Plan
*Referring Location Name
select
Abrazo Arizona Heart
Abrazo Arrowhead
Abrazo Central
Abrazo Scottsdale
Abrazo West
Allegiant- Mesa
Allegiant- Phoenix
Anthem (N. Mnt)- AKDHC Office
Arrowhead-AKDHC Office
Banner Baywood
Banner Boswell
Banner Boswell-SNF
Banner Cardon
Banner Del Webb
Banner Desert
Banner Desert- AKDHC Office
Banner Estrella
Banner Gateway
Banner Heart
Banner Ocotillo Medical Center
Banner Rehab East
Banner Rehab Hospital West
Banner Thunderbird
Banner University Phoenix
Banner University Tucson
Banner University Tucson- South
Baseline (B. Dst)- AKDHC Office
Baywood-AKDHC Office
Boswell (Sun City West)- AKDHC Office
Buckeye (Goodyear)- AKDHC Office
Bullhead City- Office
Camelback- AKDHC Office
Canyon Vista
Catalina Care-SNF
Chandler- AKDHC Office
Chandler Regional
Cobalt Rehab
Cornerstone
Cottonwood- AKDHC Office
CuraHealth- Northwest Phoenix
CuraHealth-Tucson
Deer Valley- AKDHC Office
Dialysis Unit Transfer
Dignity East Valley Rehab
Douglas (Sierra Vista)- AKDHC Office
Encompass- NW Tucson
Encompass- Scottsdale
Encompass- Valley of the Sun
Encompass-East Valley
Encompass-Tucson
Flagstaff- AKDHC Office
Flagstaff Medical Center
Fountain Hills (Osborn)- AKDHC Office
Goodyear- AKDHC Office
Green Valley- AKDHC Office
Havasu Regional
Honor Health Sonoran Crossing Medical Center
Honor Health-Deer Valley
Honor Health-North Mountain
Honor Health-Osborn
Honor Health-Rehab
Honor Health-Shea
Honor Health-Thompson Peak
Hospital - FKC Direct
Hospital ICU
Hualapai Mountain
Kingman- AKDHC Office
Kingman Regional
Lake Havasu- AKDHC Office
LaPaz Regional
Maryvale- AKDHC Office
Mayo
Mercy Gilbert
Mountain Valley- Rehab
Mountain Vista
Mountain Vista- AKDHC Office
Nogales (St. Mary's)- AKDHC Office
North Mountain- AKDHC Office
North Mountain Rehab
Northwest Medical Center
Oro Valley Medical Center
Osborn Town Center-AKDHC Office
Paradise Valley- AKDHC Office
Park Ave
Parker (Lake Havasu)-AKDHC Office
Payson (Chandler, B. Dst, Mnt Vista)- AKDHC Office
Phoenix Childrens
Pima- AKDHC Office
Plaza
Polacca (Flagstaff)- AKDHC Office
Prescott- AKDHC Office
Prescott Valley (Prescott)- AKDHC Office
Promise- East Valley
Queen Creek (Mnt Vista)- AKDHC Office
Safford (Sierra Vista)- AKDHC Office
Salt River Clinic (Pima)- AKDHC Office
San Carlos (B. Dst)- AKDHC Office
Select Specialty- Banner UMC
Select Specialty- St. Joes
Sells (Sells)- AKDHC Office
Show Low-AKDHC Office
Sierra Vista- AKDHC Office
St. Joes- Phoenix
St. Joes- Tucson
St. Joes- Westgate
St. Luke's
St. Luke's-Tempe
St. Mary's
Summitt
Sun City- AKDHC Office
Sun City West- AKDHC Office
Thomas- AKDHC Office
Thompson Peak (Osborn)- AKDHC Office
Thunderbird- AKDHC Office
Tucson East- AKDHC Office
Tucson Marana- AKDHC Office
Tucson Medical Center
Tucson Northwest- AKDHC Office
Tucson Oro Valley (Northwest)- AKDHC Office
Tucson St. Mary's- AKDHC Office
Tucson University- AKDHC Office
VA
Valley View
Valleywise Health Clinic-AKDHC Office
Valleywise Health Hospital
Verde Valley
WARMC
Westgate-AKDHC Office
Wilcox (Sierra Vista)- AKDHC Office
Winslow (Show Low)-AKDHC Office
YRMC-East
YRMC-West
Other (please specify)
*Dialysis Modality
HD
Patient Status
ACUTE
ACUTE T/I: FROM OUR UNIT
ACUTE T/I: NON-DIALYSIS UNIT
ACUTE T/I: PART-TIME RESIDENT
ACUTE T/I: SWTCH DR/PRACTICE
NEW ESRD
T/I: FROM OUR UNIT
T/I: NON-DIALYSIS UNIT
T/I: PART TIME RESIDENT
T/I: SWITCHED DR/PRACTICE
TRANSIENT
COVID-19 Status
COVID-19 Positive
COVID-19 PUI
COVID-19 Negative
CONTACT INFORMATION
*Case Manager Name
*Contact Number
Contact Fax Number
Contact Email
ORDERING PHYSICIAN INFORMATION
*Ordering Physician
select
Abdelaziz, Abubakr, M.D.
AbuDaff, Naief, M.D.
Acharya, Chirag, M.D.
Ahmed I, Irfan, M.D.
Ahmed J, Jamil, M.D.
Alamiry, Muhammad, M.D.
Amin, Yogesh, M.D.
Aslam, Kaleem, M.D.
Atalla, Jamal, M.D.
Bai, Liqun, M.D.
Bala, Radha, M.D.
Bani Hani, Samer, M.D.
Bayazid, Saeb, M.D.
Bechtold, Lance, M.D.
Belen, Cary, D.O.
Bista, Amar, M.D.
Boyadjian, Sevag, D.O.
Bueno, Damaso S, M.D.
Burstein, David, M.D.
Buxton, Suzan, M.D.
Campion, Vincent, M.D.
Carter, Charles, M.D.
Chalasani, Rajendra, M.D.
Channis, Basel, M.D.
Chaudhary, Asad Junaid, M.D.
Chen, Ang, M.D.
Chindo, Joseph, M.D.
Choi, Jeans, D.O.
Chugh, Tarun, M.D.
Church, Lynn , NP
Colattur, Shyam, M.D.
Cortez, Andrew J, D.O.
Cumbria, Wayne, M.D.
Dahl, Katharine, M.D.
DeLong, Michael, M.D.
Desai, Sachin, M.D.
Dixon, Megan B, M.D.
Donovan, Brenda, NP
Duarte, Ricardo, FNP
Facurib, Jennifer, NP
Fadia, Amit, M.D.
Ferraro, James, D.O.
Figueroa, Michelle , AGACNP-BC
Fischer, Linda, FNP-C
Fulmore, Nancy, AGACNP-BC
Garg, Ameesh, M.D.
Gembala, Matthew, M.D.
Goswami, Puja, M.D.
Hachem, Hassan, M.D.
Hanna, Abboud, M.D.
Hernandez, Priscila , NP
Ho, Warren, M.D.
Howlader, Anjuman A, M.D.
Kartoumah, Almutaz, M.D.
Kim, Jin K., M.D.
Krieble, Barry, M.D.
Laurel, Edguardo, M.D.
Lee, Sungchun, M.D.
Leon Velarde Carreno, Ernesto, M.D.
Leopold, Pete S., D.O.
Lien, Howard, M.D.
Lindner, Clare, M.D.
Liu, Zhao, M.D.
Logan, Joy L, M.D.
Manalo, Anna, FNP-C
Mishler, Rick, M.D.
Misra, Suman, M.D.
Moasser, Amir, M.D.
Moffitt, Robert A, M.D.
Morales, Alejandro, M.D.
Moreno-Ortiz, Juan Pablo, M.D.
Mousa, Maher M, M.D.
Mumick, Guneet, M.D.
Mustafa, Esmat, M.D.
Nabha, Anil, M.D.
Narayanan, Rajnikanth, M.D.
Neagra, Christopher, D.O.
Nemr, Saed, M.D.
Neyra, Roxana, M.D.
Nica, Romanita D., M.D.
Nimri, Alexander , M.D.
Nino Mojica, Jessica, M.D.
Opiyo, Grace, NP
Oster, Gertrude, NP
Packer, Jeffrey, D.O.
Pedapati, Shilpa, M.D.
Perveze, Zeeshan, M.D.
Philobos, Amir, M.D.
Pokharel, Milap, M.D.
Pozo Garcia, Leonardo, M.D.
Prieto, Roseanne, NP
Qaqish, Ibrahim, M.D.
Rashid, Asma, M.D.
Raskin, David, M.D.
Reyes, Carlos, M.D.
Robey, Jean, M.D.
Rokkam, Vamsi, M.D.
Sacks A, Andrew, D.O.
Sacks P, Paul, M.D.
Salehi-Rad, Reza, D.O.
Sanna, Sathish, M.D.
Santos, Peter, D.O.
Savedchuk, Solomiia, M.D.
Seaton, Robert, M.D.
Shakil, Bassam, M.D.
Sinanan, Rajiv, M.D.
Singh, Harnath, M.D.
Soni, Jatinder, M.D.
Sullivan, Rachel, NP
Swaminathan, Ariv, M.D.
Syed, Atiq, M.D.
Tan, Xin Y, M.D.
Thakur, Tushar, M.D.
Thomas, Ann, M.D.
Ting, Steven, M.D.
Uddin, Muhammad, M.D.
Ungar, Scott, D.O.
Vo, Victoria, M.D.
Wang, Shouwen, M.D.
Whitney, Charis E, M.D.
Whittman, David T, M.D.
Yang, Zhongguang, M.D.
Zaharia, Valentin, M.D.
Zar, Tausif, M.D.
Zaw, Yuzana Khin, M.D.
Zhao H, Hui J, M.D.
Zhao J, Joseph, M.D.
Zou, Lixian, M.D.
Zuidema, Dana, FNP
Other (please specify)
Additional Dialysis Placement Information
Notes
(500 ch)
*Required Fields