Refer a Patient

Please submit the secure form below to refer your patient to a provider at Mass General's Department of Urology. This form should not be used for appointments needed within 72 hours. In those cases, please call us at 857-238-3838.

To request an inpatient transfer, please call 1-855-468-6642 (1-855 GO TO MGB).

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 857-238-3838.

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

Daytime Phone

To facilitate processing, please provide insurance plan name if known

Is the patient aware of this referral?

YesNo

Reason for referral

Describe reason for referral and include ICD10 code if known

Referring Physician

First name

Last name

Are you the referring physician?

YesNo

NPI

Daytime Phone

Fax

Practice name

Address line 1

Address line 2

City

State

Zip Code

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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Refer a Patient

Refer a Patient

Operations Update for Referring Providers