Munson Dialysis Travel Request Form

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Patient Travel Request Form

A minimum 30 days notice is required.

Patient name:
Patient email:
Date(s) of request:
Date returning to home unit:
Name of unit(s):
Phone number:

Are you willing to accept any unit?
Yes No

Are you willing to accept a different city?
Yes No

Complete if treatment is needed at more than one unit during your trip:

2^nd Unit:		City:
State:		Phone:

3^rd Unit:		City:
State:		Phone:

4^thUnit:		City:
State:		Phone:

Local address and phone number (where you will be staying):

Address:
Phone:

Please be aware that changes in travel arrangements, after being accepted, are the responsibility of the patient. If patient does not have secondary insurance or if insurance is not accepted by visiting unit, patient may be responsible for payment in advance.

If you are a Munson Healthcare patient and have a compliment, concern, or complaint, please contact one of our Patient Liaisons.

We welcome your comments and suggestions about this Web site.