Body Dialysis Patient Travel Request Form Webform A minimum 30 days notice is required. Once your request is received, a facility representative will contact you for additional information. 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? No Yes Are you willing to accept a different city? No Yes Complete if treatment is needed at more than one unit during your trip: Second Unit City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code 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. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.