​Heart Transplant Referral Checklist

When referring patients to the Heart Transplant Program at UPMC, please include the information listed below.

Demographic Summary

  • Patient name
  • Patient date of birth
  • Patient address
  • Patient phone number
  • Patient social security number
  • Emergency contact information (including emergency contact’s home and cell phone numbers)

Insurance Information

  • Name of subscriber
  • Subscriber’s relationship to patient
  • Identification number
  • Group number

Clinical Summary

  • Pertinent medical records such as last clinic note or inpatient H&P
  • Lab test results
  • Transthoracic echo (TTE)
  • RHC/LHC/coronary angio results
  • Cardiopulmonary stress test
  • Details regarding any past history of cancer
  • Immunization history
  • Any other pertinent information that will help the committee make an informed decision

Referring Physician Information

  • Referring physician name
  • Referring physician phone and fax numbers
  • Primary care physician name

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For help in finding a doctor or health service that suits your needs, call the UPMC Referral Service at 412-647-UPMC (8762) or 1-800-533-UPMC (8762). Select option 1.

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