Kidney Transplant Referral Form

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Please 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. 

After you submit the form, you will be directed to a page that lists your next steps, including sending our office documentation:

  • GFR<20 (if applicable)
  • Form 2728 (if applicable)
  • Up to date documentation of health screenings

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:

Manage Your Health Information Using MyBaystate
Sign in online or download the MyBaystate patient portal app to access your health information.

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