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Kidney Transplant Referral Form

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:

Contact Information

Patient Information

I, or my authorized representative, request and/or permit the disclosure of the above information with the Baystate Health Kidney Transplant Program.

  1. This authorization is voluntary.
  2. I have the right to revoke this authorization at any time in writing, except to the extent that action has already been taken based on this authorization.
  3. Communications may be electronic, such as email, and such methods may not always be secure. There is no guarantee, assurance, or warranty of confidentiality.
  4. I agree to hold Baystate Health harmless from any claims or liabilities that may result from the electronic communications.
  5. This authorization includes disclosure of information that may relate to demographic, alcohol use, drug use, and other medical test information.