Refer a Patient

Please submit the secure form below to refer your patient to a provider at Massachusetts General Hospital. This form should not be used for appointments needed within 72 hours. In those cases, please call us at 617-726-2784.

After you submit this form, our office will work directly with the patient to schedule an appointment and assist with registration if needed. Referring providers will be notified of appointment details. You may also speak with a representative directly Monday – Friday, 8:30 am to 5:00 pm EST by calling 617-726-2784.

If this is a Spine referral, please call our Spine Center at 617-724-8636

Important note: Some questions on this form may appear or disappear based on your responses.

* indicates a required field.

Patient Information

First name

Last name

Date of birth

MM/DD/YYYY

Phone number (to contact the patient with appointment information)

To facilitate processing, please provide insurance plan name if known

Is the patient aware of this referral?

YesNo

Spine referral, please call our Spine Center 617-724-8636

Reason for referral

hidden section

DepartmentToRefer

Describe reason for referral and include ICD10 code if known

Referring Physician

First name

Last name

NPI

Phone

Fax

Practice name

Address line 1

Address line 2

City

State

Zip Code

The Mass General Difference

Conditions & Treatments

Patients & Visitors

Research & Innovation

Orthopaedic Surgery

Refer a Patient

Refer a Patient