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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

*This referral is being completed by, or on behalf of

*Referring Provider

*Phone Number

Patient Information

*Name

*Date of Birth

*Phone Number

*Secondary Contact Name

*Secondary Contact Phone Number

*Street Address

Apartment #

*City

*State

*Zip Code

*Primary Insurance Plan/Member ID

*Primary Insurance Plan Group Number

Secondary Insurance Plan/Member ID (if applicable)

Secondary Insurance Plan Group Number (if applicable)

Other Insurance Information (if applicable)

*Primary Diagnosis/Cause of ESRD

If you need an interpreter, please select your spoken language

Other Language (if not listed above)

*Does the patient need help with

*Best day/time to reach patient

*Is the patient/are you on dialysis?

*Dialysis Unit

*Dialysis Schedule

*Height (feet/inches)

*Weight (pounds)

*GFR

*2728

*Smoking?

*Alcohol abuse?

*Substance abuse?

*History of smoking or alcohol/substance abuse

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

This authorization is voluntary.
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.
Communications may be electronic, such as email, and such methods may not always be secure. There is no guarantee, assurance, or warranty of confidentiality.
I agree to hold Baystate Health harmless from any claims or liabilities that may result from the electronic communications.
This authorization includes disclosure of information that may relate to demographic, alcohol use, drug use, and other medical test information.