Request Dialysis Treatment at Mount Sinai Kidney Center - East River Plaza

If you are a DaVita patient or desire treatment at a DaVita center, and you need dialysis treatment within the next 7 days, call DaVita at 1-866-889-6019 and a dialysis placement specialist will assist you.

Otherwise, if you have more than 7 days to plan and you are already a DaVita patient, you may use this form to request DaVita assistance in placing you at any center of your choice. Please have your destination address and ZIP code available before you begin.

Please note: Do not use this form if you are not a current DaVita patient and you wish to be placed in a non-DaVita center. Information submitted by a DaVita patient, or individuals who wish to become DaVita patients, will be governed by DaVita's Notice of Privacy Practices

Important note for DaVita peritoneal dialysis patients: If you wish to travel and would like a back-up center call
1-866-889-6019.

You are requesting treatment at:

Mount Sinai Kidney Center - East River Plaza
520 E 117th St 4th Fl, New York, Ny 10035

Phone: 212-987-7208
Fax: 646-537-9688
Reference #: 101929

* Required information

Visitor Travel Information

Arrival Date

First Requested Treatment Date

Last Requested Treatment Date

Departure Date

Total Number of Treatments

Purpose of Travel

Destination Street

Destination City or Town

State Where Center is Located

Destination Zip Code

Phone Number

Distance Willing to Travel to Center

Your Information

Is this Placement Request for a DaVita Patient?

Patient Information

Patient First Name

Middle Initial

Patient Last Name

Patient Date of Birth

Patient ZIP Code

Patient Phone

Patient Email

Patient's Current Dialysis Center Information

Home Facility Name

Home Facility City

Home Facility State

Home Facility Phone Number

Home Facility Fax

Name of Social Worker/Representative

Treatment Information

Dialysis Access Type

Treatment Schedule

Treatment Schedule Flexibility

Does Patient Require Isolation

Primary Insurance