Request Dialysis Treatment at DaVita Shiloh Dialysis

You are requesting treatment at:

DaVita Shiloh Dialysis 1095 N Green Mount Rd, Belleville, Il 62221-3303

Phone: 1-800-424-6589 Fax: (618) 628-1459

If you need dialysis treatments within the next 7 days, call 1-800-244-0680 and a Guest Services Contact Center Teammate will assist you. Otherwise, if you have more than 7 days to plan, complete this form in its entirety. Please have your destination address and or zip code available before you begin. This information is required in order to find the closest available facility to your destination.

Note: You only need to submit this form once per arrival date. If we can't find availability at this particular center on the date you requested, we will try to find the closest available center.

Important note for Peritoneal Dialysis patients: If you're wishing to travel and would like a back-up facility call 1-800-244-0680.

Thank you!

All fields are required unless marked "optional."

Section: 1 of 6

Visitor Travel Information

* To request permanent placement at a DaVita center, please call 1-866-475-7757.
* For placement within the next 7 days, please call 1-800-400-8331. This form requires a minimum of 7 days notice.

Type of Placement:

Arrival Date:

First Requested Treatment Date:

Last Requested Treatment Date:

Departure Date:

Total Number of Treatments:

Purpose of Travel:

Destination Street:

Destination City:

Destination State:

Destination ZIP Code:

Phone Number:

Distance Willing to Travel to Facility:

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Your Information

Is this Placement Request for a DaVita Patient?

Email:

Section: 3 of 6

Patient Information

Patient First Name:

Patient Middle Initial:

Patient Last Name:

Patient Date of Birth:

Patient ZIP Code:

Patient Phone Number:

Patient Email:

Section: 4 of 6

Patient's Current Dialysis Center Information

Dialysis Center Name:

Dialysis Center City:

Dialysis Center State:

Dialysis Center Phone:

Dialysis Center Fax:

Name of Social Worker/Representative:

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Treatment Information

Access Type:

Treatment Schedule:

Treatment Schedule Flexibility:

Does Patient Require Isolation:

Length of Treatment:

Primary Insurance Type:

Name of Primary Insurance Company:

Name of Secondary Insurance Company:

Section: 6 of 6

Additional Information

Additional Information or Special Handling: