PRINEd Physician Referral Form Nephrologist*PrinceAliTepedinoCohenSedkiBhasinDilmetinGordon-DubsWengerLaxIoannouChunLibermanWuFriedmannErlichSwartzPinkhasovParikhRubelOTHERPatient Name*First and Last NameReferral for:*PRINEdCCMRPMCan you list the patient's 2-3 chronic conditions?RPM deviceBlood PressureScaleWhich PRINEd Class?BASICSESRD CHOICESBOTHWhat would you predict your patient's PAM Activation Level to be?Level 1 (Disengaged and Overwhelmed)Level 2 (Becoming Aware but still Struggling)Level 3 (Taking Action and Gaining Control)Level 4 (Maintaining Behaviors and Pushing Further)Last eGFR or CrCl (provide value and date please)Estimated time to dialysis*1 month or less1-3 months3-6 monthsmore than 6 monthsDo you have a Dialysis preference for this patient?In-center HemodialysisHome HemodialysisPeritoneal DialysisEither home modalityNo preferenceDoes patient have access for dialysis?*YesNoWhat type of access? Who placed access? When was it done?Do you have a preference as to what type of access and who you would like to send patient to get access?Is patient a Transplant candidate?*YesNoMaybeWhat is your preferred Transplant Center?NorthwellNYU / WinthropMt. SinaiStony BrookRogosin (Cornell)ColumbiaAny comments or things you think we should know about your patient before we contact him/her?