Refer a Patient

Please submit the secure form below to refer your patient to a provider in the Pancreas Transplant Program at Massachusetts General Hospital. This form should not be used for appointments needed within 72 hours. In those cases, please call us at 877-644-2860.

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 877-644-2860.

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

Describe reason for referral and Include ICD10 code if known

Is the patient currently listed at another transplant center?

Has the patient been evaluated for a transplant in the past?

Has the patient ever received a transplant?

Is the patient currently on dialysis?

Which modality?

Hemodialysis schedule

Referring Physician

First name

Last name

Are you the referring Physician?

Yes

NPI

Phone

Fax

Practice name

Address line 1

Address line 2

City

State

Zip Code

Medical Specialty

Preferred Method of Communication for Status Updates

If you selected Physician Gateway above and are not currently enrolled, you will receive an email including enrollment instructions within 3 business days.

Physician Gateway is our secure online portal which enables you to submit referrals for patients, monitor patient status and order imaging tests.

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