Refer a Patient

For current and prospective patients interested in more information about xenotransplantation at MGH, please visit www.mghxenotransplant.org.

To ensure a smooth and expedited intake process:

Please encourage your patient to call Mass General registration at 866-211-6588, Monday-Friday, 8:00 am to 5:00 pm ET.

Please submit the secure form below to refer your patient to a provider in the Kidney Transplant Program at Massachusetts General Hospital. Be sure to submit the following required documents via fax: 617-726-0822.

2728 CMS ESRD form (if on chronic dialysis)
Recent nephrologist visit note
Recent ED discharge summary
Pertinent test results (e.g., kidney biopsy)
Insurance information

Incomplete submissions may result in delays.

* indicates a required field.

Patient Information

First name

Middle initial

Last name

Date of birth

MM/DD/YYYY

Legal sex

Race

Ethnicity

Language

Please specify

Name of parent/guardian if under 18 years old

Address line 1

Address line 2

City

State

Zip Code

Height

Weight

BMI

Primary phone

Other contact information

Insurance payer

Insurance policy #

Dialysis?

YesNoIf on dialysis, 2728 form must be included in referral submission.

Dialysis days

MWFTTS

Dialysis center name

Dialysis center address

Current eGFR?

Primary diagnosis (ICD10 code)

Date Obtained eGFR

MM/DD/YYYY

As of July 2022, UNOS has removed the race variable in eGFR calculation. Providing the race-neutral eGFR and date obtained can identify affected patients potentially eligible for increased time on the transplant waitlist.

Referring Physician

First name

Last name

Date

MM/DD/YYYY

NPI

Office address

City

State

Zip Code

Phone

Contact person

Is the patient listed at other transplant center(s)?

Yes

What is the center name?

Is the patient aware of this referral?

Yes

Please select the preferred Kidney Evaluation Clinic location for your patient's initial evaluation.

Preferred Method of Communication

Physician Gateway is our secure online portal allowing real-time access to your patients’ medical record. Physician Gateway enables you to submit referrals for patients, monitor patient status and order imaging tests.

To learn more or to enroll, please visit the Physician Gateway.

If you would like to schedule Provider Education or Transplant Referral Process training for your team, please contact Stacy Jean-Claude at 617-726-0037 or by email at sjean-claude@mgh.harvard.edu.

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Equity in Kidney Transplantation (EqKT) Initiative