Nicoletti Kidney Transplant Center

at Jefferson Transplant Institute

833 Chestnut Street, Suite 138
Philadelphia, PA 19107
T 888-855-6649
F 215-503-4332

On behalf of the thousands of patients waiting for a life-changing kidney transplant in

the United States, we thank you for your willingness to be evaluated for a living kidney
donation. The Jefferson Transplant Institute has a greater than forty year history of
performing successful live donor kidney transplants. You are in the best of hands with an
outstanding team of physicians and surgeons, nurses, social workers and pharmacists, all
dedicated to your health and well-being.

The enclosed booklet should help in answering basic questions and throughout your
donation journey; however the best resource is our team of transplant professionals. If you
have any questions about any part of our process, what you should expect, or what the
kidney recipient should expect, please don’t hesitate to ask us. It is our goal to make sure
you are always fully informed.

Please follow the below instructions to complete the needed forms within this packet:
1. Please complete our online health questionnaire via the following link:
JeffersonHealth.org/LivingDonorForm or you may return the enclosed health
questionnaire in the envelope provided by faxing it to the Nicoletti Kidney Transplant
Center at 215-503-4332 or emailing it to livingdonor@jefferson.edu.
Please do not give your health questionnaire to the laboratory.
2. Upon receipt of the completed health questionnaire, two members of our team, an
Independent Living Donor Advocate and a Nurse Coordinator, will reach out to you to
discuss living donation.
3. Once you have spoken with the Independent Living Donor Advocate and Nurse
Coordinator, please go to your outpatient laboratory of choice to have the blood test
drawn to determine your blood type. The order for this test is included within this packet.

When we receive the medical screening questionnaire and blood type information, the
transplant team will call to discuss the next steps for evaluation. At that time, we can review
the overall process of becoming a kidney donor and we will answer any questions you may
have. You can also call us at 888-855-6649.

Living kidney donation is a selfless act of kindness and true heroism. We respect your gift
to the highest extent and we will make certain that you are treated accordingly throughout
your evaluation, donation and experience after discharge.

See below for Jefferson website links to educational videos for the Kidney Transplant
Program, Living Donor Kidney Program and the Kidney Champion Program.
a. JeffersonHealth.org/KidneyTransplant
b. JeffersonHealth.org/LivingDonor
c. JeffersonHealth.org/KidneyChampion

Thank you for making life possible again.

Very Sincerely,

The Jefferson Transplant Institute

Nicoletti Kidney Transplant Center
833 Chestnut St, Suite 138
Philadelphia PA 19107
Phone 1-888-855-6649 Fax 215-503-4332

LIVING KIDNEY DONOR SCREENING QUESTIONNAIRE

For office use only:

Date received
BMI
Donor MRN Declined
Coordinator Comments:

Donor Name (Last, First) Collado Emília Date 12/02/20

SSN 139887691 Age 51 DOB 01/05/69 Gender F
Height 5/4 Weight 140 Blood type O positiv Marital status Merried
Race  Caucasian  African American  ✔ Hispanic  Asian Pacific  Other
Address: 314 south 4th stress City Vineland State Nj Zip 08360
Phone number: Home Cell 8564057326 Work 856 418 5433
Email Emilia collado53@yahoo.com Best way to contact Be phone Time Anytime
Family/primary care physician’s name Justina Obara
Address: 785 Sherman ave City Vineland State Nj Zip 08360
Phone number 856 451 4700 Fax number
Recipient name: Relationship Wife
Listed for transplant 
✔ no  yes

Highest education level:

 None  Grade school (1-8)  ✔ High school or GED  Bachelor’s degree  Post-graduate degree
Employment status:  ✔ Full time  Part time  Occupation 

Are you on disability?  Yes  ✔ No. If yes, please state reason 

920259 (REV. 12/18)

SECTION 1: PAST MEDICAL HISTORY
Have you ever been treated for high blood pressure?  ✔ No  Yes

Have you ever been told that you have heart disease?  ✔ No  Yes

Do you get frequent chest pains?  ✔ No  Yes

Have you ever had a heart attack/ bypass surgery/ angioplasty or stent placement?  ✔ No  Yes
Have you ever had a stress test within the last year?  No  Yes
✔
Have you ever had a stroke?  ✔ No  Yes
If answered yes to any of the above questions, please provide details 

Have you ever been treated for diabetes or high blood sugar including gestational diabetes during
pregnancy?  ✔ No  Yes
If yes, how many years ago were you first treated? 
Did you use  diet  pills  insulin

SECTION 2: OTHER MEDICAL PROBLEMS

Cancer  ✔ No  Yes Melanoma ✔ No
  Yes
Lung   No  Yes
✔ COPD/Emphysema ✔ No
  Yes
Tuberculosis ✔ No  Yes Pneumonia ✔ No
  Yes
Asthma  ✔ No  Yes HIV ✔ No
  Yes
Gastric/ intestinal issues ✔ No  Yes Acid reflux/ ulcers ✔ No
  Yes
Kidney Stone  No  Yes
✔ Gallbladder stone/ disease ✔ No
  Yes
Pancreatitis  ✔ No  Yes Liver disease ✔ No
  Yes
Hepatitis ✔ No  Yes Bleeding or clotting problems ✔ No
  Yes
Urinary infection/cancer  ✔ No  Yes Bladder infection/cancer ✔ No
  Yes
Bladder or kidney stones   No  Yes
✔ Prostate Problems  No  Yes
Sexually transmitted diseases  ✔ No  Yes Kidney disease ✔ No
  Yes
Protein in urine ✔ No  Yes Blood in urine ✔ No
  Yes
Neurological disease  ✔ No  Yes Seizure ✔ No
  Yes
Lupus   No  Yes
✔ Paralysis/ Stroke ✔ No
  Yes
Arthritis   No  ✔ Yes Neuropathy ✔ No
  Yes
Headaches/ Migraines  ✔ No  Yes
Obstetrics or gynecological problems (cancer/ fibroid/ endometriosis/ polycystic ovaries)  No  Yes
Pregnancies/ miscarriages/ abortions  No  Yes
If answer to any of the above questions is yes, please provide details
Endometriosis




SECTION 3: SURGICAL HISTORY

List the surgical operations you have had in the past Date
2 c section 07/21/91
01/31/94

920259 (REV. 12/18)

SECTION 4: MEDICATION LIST
Levó thyroxine 200

SECTION 5: MEDICATION OR FOOD ALLERGIES

List the medications or foods you are allergic to and the reaction you had when you took them:
None

SECTION 6: FAMILY HISTORY

Which of these diseases are found among any of your parents, brothers, sisters, extended family or
children?
 diabetes ✔ high blood pressure  kidney cancer  cancer  kidney disease
 coronary artery disease  dialysis dependent  transplant  others




SECTION 7: PSYCHO-SOCIAL INFORMATION

How often do you speak or see the recipient? 
Please tell us what motivated you to want to be considered as a living donor? Give my husband a better
Cualyty life
Cigarette smoking  never  ✔ quit smoking at age 33 # 1 packs per day
 started smoking at age 18 still smoking # packs per day
Alcohol  never  drink socially  past heavy drinker  present heavy drinker
✔
Details 
Intravenous drug use  ✔ never  quit within past year  quit over a year ago  still using
Details 
Other illicit/ recreational drug use  ✔ never  quit within past year  quit over a yr ago  still using

Details 
Have you ever been treated for substance use?  ✔ No  Yes

If yes, when and where? 

Have you ever been diagnosed with depression, anxiety, schizophrenia, bipolar disorder, personality
disorders?  ✔ No  Yes

If yes, please provide details 

Have you ever taken medications and/or received therapy because of depression, anxiety or other mental
illness or emotional problems?  ✔ No  Yes
If yes, please provide details, including provider of treatment 


Have you ever had thoughts about hurting yourself or attempted suicide?  ✔ No  Yes
If yes, please provide details 


920259 (REV. 12/18)

 ABO – EXTERNAL ORDER

Date:
Patient Name:
DOB:

BLOOD TYPE (ABO/Rh)

(Please subtype ABO "A" group for RBC antigen typing only)
(Diagnosis code Z52.4) – LIVING DONOR

Please forward above testing results to:

Nicoletti Kidney Transplant Center
at Jefferson Transplant Institute
Attn: Living Donor Transplant Coordinator
833 Chestnut Street, Suite 138
Philadelphia, PA 19107
T 888-855-6649
F 215-503-4290

Pooja Singh, MD
Medical Director, Kidney & Pancreas Transplantation
Thomas Jefferson University Hospital

LabCorp Account #: 37015770 Quest Account #: 97512209-8

IMPORTANT NOTICE, PLEASE READ:

Behind this notice is a billing letter. In order for you to AVOID receiving bills for services
rendered as part of the donor evaluation, you must present this billing letter when you
arrive at the testing facility.

If you have any trouble with the testing center accepting this billing letter, please contact
Felisha Roberts, Transplant Billing Manager at 215-503-5051. If Felisha is away from her
desk, please contact Brenda Davis, Lead Financial Coordinator at 215-955-0401, or your
live donor coordinator.

If at any point throughout the evaluation process you do receive a bill, please send a
scanned copy of the bill to your living donor coordinator so that we can correct the
claims in the system.

Thank you for considering live donation and for choosing Jefferson!

Lauren Palo, MHA, BSN, BS, RN, PMP

Associate Administrator, Transplant Services
Thomas Jefferson University Hospital
 INTERNAL BILLING LETTER
TRANSPLANT DONOR

Appointment Date:
To Whom It May Concern:

Note: For any donor undergoing radiology testing fax this letter to 215-503-1848.
Please DO NOT give the donor a letter containing the recipient’s personal information.

Patient Name:
MRN:
DOB:

The above patient was referred to your facility to undergo live donor evaluation testing.
Please register the patient using the Jefferson transplant guarantor account so that all
related service bills could reach the Transplant Program for review and adequate processing.
Please do not collect, bill, or balance bill this patient’s personal insurance.

For questions please call: Felisha Roberts, Transplant Billing Manager, at 215-503-5051
or; Brenda Davis, Lead Transplant Financial Coordinator, at 215 955-0401.
 EXTERNAL BILLING – LETTER OF AGREEMENT

Date:
To:
Patient Name:
MRN:
Date of Birth:

The above Medicare patient has been referred to your facility for a transplant recipient evaluation
testing OR consultation for living organ donation candidacy. Thomas Jefferson University Hospital
(TJUH) is a Medicare Certified Kidney Transplant Program and is bound to the regulations as set forth
in the Medicare reimbursement manual. Note that only transplant evaluation services are covered by
this arrangement and not therapeutic charges.

Please sign below where indicated and fax a copy to 215-923-1848, Attn. Organ Acquisition

1. By performing the tests/consults ordered by TJUH, the testing/consult facility and/

or physician agrees to reimbursement at the rate of 100% of the current Medicare Fee
Schedule.

2. The patient above will not be billed (or balance billed) by your institution for tests ordered by
TJUH for transplant evaluation or living organ donation evaluation. Billing details are below.

We agree to the billing terms detailed above in items 1 and 2 above:

Emilia collado

Print / Sign /Date
Authorized Representative of Test/Consult Performing Facility

Lauren Palo, MHA, BSN, BS, RN, PMP

Associate Administrator, Transplant Services
Thomas Jefferson University Hospital

Billing Instructions:
Jefferson Transplant Institute
Attn: Organ Acquisition
833 Chestnut Street, Suite 610
Philadelphia, PA 19107

For questions please call: Felisha Roberts, Transplant Billing Manager, at 215-503-5051
or; Brenda Davis, Lead Transplant Financial Coordinator, at 215 955-0401.

LabCorp Account #: 37015770 Quest Account #: 97512209-8