Please submit the secure form below to refer your patient to a provider at Mass General.

After you submit this form, Mass General staff will work directly with the patient to schedule an appointment and assist with registration if needed. Referring providers will be notified of appointment details.

This form should not be used for appointments needed within 72 hours; in those cases or with other questions, please call the Referral Management Office Monday through Friday, 8:30 am-5:00 pm, at 855-477-4755.

Required fields are marked with an *

Referring physician first and last name* 

Referring physician NPI#* 

Direct phone number for referring physician* 

Referring physician email address* 

Referring physician fax number* 

Referring practice name* 

Referring practice mailing address* 

Preferred method of communication for status updates* 

Are you the referring physician?* 

Your name (if you are not the referring physician)

Is the patient aware of this referral?* 

Preferred Mass General provider or specialty* 

Patient first and last name* 

Patient birth date* 

Patient phone number (to contact the patient with appointment information)* 

Reason for visit* 

Check the box if you would like to be registered for the Mass General Referral Portal, a secure online site to make referrals and monitor patient status. You will receive a confirmation email with login information within 24 hours.