PATIENT REFERRAL FORM  

For International Patients and Referring Physicians

If you wish to be referred to a Partners hospital, please fill out the referral form below. You can submit the information in either of two ways:

  • Press the send button and transmit the form electronically
  • Press the print button and either fax or mail the form to:

Partners HealthCare International
100 Cambridge Street, 20th Floor
Boston, MA  02114

Our fax number is +1 (617) 535-6410.

DATA SECURITY AND CONSENT MESSAGE

PARTNERS INTERNATIONAL WILL USE YOUR REFERRAL FORM TO BEGIN ARRANGING FOR CARE WHERE APPROPRIATE. THE INFORMATION YOU PROVIDE WILL BE KEPT PRIVATE IN ACCORDANCE WITH PARTNERS' CONFIDENTIALITY POLICIES, AND WILL BE SEEN BY A LIMITED NUMBER OF AUTHORIZED INDIVIDUALS AS NECESSARY, INCLUDING CERTAIN HEALTH CARE PROVIDERS AND THE INTERNATIONAL PATIENT COORDINATORS. IF YOU NEED TO CHANGE THIS INFORMATION, PLEASE CONTACT US (FAX: +1 (617) 535-6410, OR PHONE: +1 (617) 535-6400). WE MAY CONTACT YOU IF WE NEED TO VERIFY OR OBTAIN FURTHER INFORMATION. YOU SHOULD UNDERSTAND THAT THIS REFERRAL FORM DOES NOT ESTABLISH A DOCTOR-PATIENT RELATIONSHIP; YOU MAY BECOME A PATIENT ONCE YOU COME TO PARTNERS FOR TREATMENT. AT THAT POINT, THIS FORM WILL BECOME PART OF YOUR MEDICAL RECORD.

CHILDREN UNDER EIGHTEEN (18) MAY NOT SUBMIT THIS FORM VIA THE INTERNET.

PARTNERS CANNOT ABSOLUTELY GUARANTEE THE CONFIDENTIALITY OR SECURITY OF SUCH ELECTRONIC TRANSMISSIONS.

Who recommended our services to you?
Relative/acquaintance/friend
Insurance company
Embassy
Employer
Other, please specify:

Please check one:
Self-Referral Physician Referral
Referral request:
2nd Opinion Physician Consultation Hospital Admission

Do you have a preference for one of the following hospitals:
Brigham and Women's Hospital
Massachusetts General Hospital
Dana-Farber Cancer Institute (adult cancer services only)
No preference

Patient Information
Patient's Name (Required)

Gender (Required): M F

Date of Birth (Month, Day, Year)

Permanent Address

City

State / Province

Country

Zip or Postal Code

Home Telephone: (Required)

Business Telephone:

Home E-mail:

Business E-mail:

Home Fax:

Business Fax:

Local Address in Boston (if available)

Local Telephone: (if available)

Local Fax:

Emergency Contact Name:

Contact's Telephone Number:

Clinical Information
Patient Diagnosis:

Patient Clinical Status:

Clinical Department or Specialty:

Anticipated Travel Dates to Boston:
From: to

Referring Physician
Name

Affiliation

Office Telephone Number

Fax Number

Emergency Telephone Number

E-mail Address

Patient Services Information

Will you need assistance with the following?

Interpreter Services
Yes No
Languages you speak:

Hospital Accommodations
Private Room Semi-private room (2 beds)
Hotel Accommodations Yes No
Number of guests traveling with you

Number of rooms needed

Hotel rating preference

Smoking Non-smoking
Transportation from Logan Airport to hotel or hospital: Yes No
Special diet during your hospital stay: No Yes
If yes, please specify diet:

Note: For self-pay patients requiring hospitalization, payment in advance is required. For some insurers and for embassy cases, we accept letters of guarantee in place of advance payment. If available, please send a detailed clinical summary along with this form.

PLEASE BE SURE TO REVIEW YOUR SELECTIONS CAREFULLY PRIOR TO SUBMISSION TO PARTNERS. WE LOOK FORWARD TO ASSISTING YOU, AND ASK THAT YOU PROVIDE AS MUCH OF THE REQUESTED INFORMATION AS POSSIBLE SO THAT WE MAY SERVE YOU BETTER.