Kidney Transplant Referral Form

Baystate Transplant Program Exclusion Criteria

Please refrain from referring patients with any active exclusion criteria:

• Open wounds
• Active cigarette smoking
• Active cancer
• Incarceration
• Experiencing homelessness
• BMI > 45

Contact our program with any questions.

Refer a Patient

Complete the form below to refer a patient to the Adult Kidney Transplant Program at Baystate Medical Center. This form may be completed by a referring physician, a patient, or someone a patient has authorized to complete the form.

Please note that this form is not intended for medical emergencies. Do not use this form for appointments needed within 72 hours. 

Please attach the following documentation using the file upload at the bottom of this form or fax copies to 413-794-2329:

1. GFR <20 documentation (if applicable)
2. Form 2728 (if applicable)
3. Documentation of Health Screenings:
   
   Colorectal screening if >45 years and <75 years
   Mammogram within a year of referral for women >45 years – 54 years
   Mammogram within 2 years of referral for women >55 years
   Cervical cancer screening for all women between 25-65 years (any of the following)
   Primary HPV test within 5 years of referral
   Co-test (HPV and PAP) within 5 years of referral
   Pap test within 3 years of referral

Someone from the Kidney Transplant Program will contact you to schedule an appointment.

Patient Consent: To refer a patient or complete the form on a patient's behalf, please ensure that you have the patient's consent. 

Start Your Referral: