Refer a Patient

Learn more about our Transplant Evaluation Program.

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 Pancreas Transplant Program at Massachusetts General Hospital. Be sure to submit the following required documents via fax: 617-726-0822.

Recent endocrinologist visit note with last hemoglobin A1c and c-peptide titer
2728 CMS ESRD form (if on chronic dialysis)
Recent nephrologist visit note, if applicable
Recent ED discharge summary
Pertinent test results (e.g., abdominal/pelvic CT scan)
Insurance information

Incomplete submissions may result in delays.

* indicates a required field.

Patient Information

First name

Last name

Date of birth

MM/DD/YYYY

Legal sex

Race

Ethnicity

Language

Please specify

Height

Weight

BMI

Name of parent/guardian if under 18 years old.

Address line 1

Address line 2

City

State

Zip Code

Primary phone

Email address

Insurance payer

Insurance policy #

Is the patient Type 1 or Type 2 diabetic?

If on insulin, how many units are taken?

Recent hemoglobin A1c

Who is the endocrinologist, if not the referring physician?

Does the patient have an abdominal/pelvic CT scan?

Does the patient have chronic kidney disease?

Who is the nephrologist, if not the referring physician?

Is the patient currently on dialysis?

Dialysis center name

Address line 1

Address line 2

City

State

Zip Code

The 2728 form must be included in the referral submission.

Current eGFR

Date obtained eGFR

MM/DD/YYY

Primary diagnosis (ICD10 code)

Referring Physician

First name

Last name

Date

MM/DD/YYY

NPI

Practice name

Address line 1

Address line 2

City

State

Zip Code

Phone

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

Is the patient aware of this referral?

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

Preferred Method of Communication

Patient Gateway is our secure online portal allowing real-time access to your medical record.

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

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