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Content
Appointment Schedule
Reimbursement Program for Living Donors (RPLD)
This form must be completed by the transplant centre in block letters.
Family name of applicant :
Given name of applicant :
Date of birth of applicant :
yyyy
Health insurance number of applicant :
mm
dd
Name of transplant centre :
Kidney
Liver
Légend
Purpose of the visit - Please refer to the legend
(If "other", please specify)
Date (yyyy-mm-dd)
Code
Comments
Code Description
L
Lab
I
Imaging
SC Surgery consultation
EX
More in-depth examination
T
Tissue typing
T
Teaching
H
Pre-surgical hospitalization
MC Medical consultation
PC Psychological consultation
O
Other
Confirmation of eligibility under the Reimbursement Program for Living Donors
-
Date of procurement surgery: :
yyyy
Date of hospital discharge :
mm
yyyy
mm
Not applicable
Pending
Not applicable
Pending
dd
dd
Is this donor signed up to the Living Donor Paired Exchange Registry ?
Yes
If so, please name the participating ho