For International
Patients and Referring Physicians
If you wish to be referred to a Partners hospital,
please fill out the referral form below.
DATA
SECURITY AND CONSENT MESSAGE
PARTNERS MEDICAL
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. 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.