Refer a Patient

Please submit the secure form below to refer your patient to a provider in the Mass General Brigham Liver Transplant Program.

Please complete this form with the information you have available and leave any unknown fields blank.

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 877-716-8440.

* indicates a required field.

Referring Physician

First name

Last name

Date

MM/DD/YYYY

Address line 1

Address line 2

City

State

Zip Code

Phone number

Reply to fax number

Contact person

Primary Care Provider

Name

Phone and fax

Address line 1

Address line 2

State

City

Zip Code

Please provide additional requests/information related to scheduling

Patient Information

First name	Last name
Sex	Address line 1
Address line 2	City
State	Zip Code
Date of birth MM/DD/YYYY	Phone number

Cell phone number

Insurance Information

To facilitate processing, please provide Insurance Plan Name, if known

Policy number

ID number

Subscriber

Benefit contact

Medical Information

Diagnosis

Please fax the following information: Recent clinic visit notes including a detailed history and physical (within the last 60 days); list of current medications; most recent labs (including BMP, LFTs, CBC, INR, tumor markers); operative/pathology reports; radiology (CT, MRI, US, and Mammogram within the past year); last pap smear exam. Please see the bottom of this page for additional instructions.

Please select preferred evaluation location

Liver Transplant Evaluation—Requested Documents

To facilitate the evaluation process, we would like to request your help in working with the patient and their longitudinal providers to gather the following information. Please let your patient know that our team is here to assist in the process and answer any questions, and that we will need to review the below documents and imaging prior to scheduling an appointment.

Requested Checklist:

Detailed medical summary including state of current condition, current medications, past medical history, surgeries and other co-morbid conditions, and any medical treatment or management of the current condition. Please include colonoscopy and/or endoscopy results and surgical procedure reports
Most recent labs including: BMP, LFTs, CBC, INR, tumor markers (AFP and CA 19-9), hepatitis A, B, and C serologies, any additional pertinent labs and ABO blood typing
All available imaging studies, including CT, MRI, ultrasounds, X-rays. Please request for imaging to be sent to us directly from the performing facility
Please send disk with imaging data OVERNIGHT to:
- 55 Fruit St, Boston, MA 02114 Warren Building 7th FL, RM 735
Liver biopsy pathology report (if performed)
Cardiac data (if performed) including EKG, echocardiogram, stress testing and right or left heart catheterization
Age appropriate cancer screening including pap smear report, mammography and chest imaging as indicated for smoking history

Please fax information to (617) 643-5576 and call (877) 716-8440 with any questions.

If your patient has not previously received medical care at Mass General Brigham, we will need to get them set up with a medical record number before we can proceed with scheduling. Please feel free to give a copy of this form to the patient so that they can contact outpatient registration at 1-866-211-6588 to obtain a medical record number. We encourage them to reach out to us for assistance and complete this step as soon as possible so that we can move forward with their transplant evaluation appointment.

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Refer a Patient

Liver Transplant Evaluation—Requested Documents