Cancer Center Physician Referral Form

Please complete this form to refer a patient with a confirmed or suspected cancer diagnosis to a University of Maryland Medical System (UMMS) Cancer Center.

Referring Provider information:

Enter full name.

Provider First Name

Provider Last Name

Suffix

Provider NPI

Point of contact for following up on referral

Phone

Fax

Email Address

Preferred Method of Initial Contact

We will use the communication method you select here to contact you to complete the referral process.

Are you the patient's primary care physician?

YesNo

Do you (provider) utilize Care Everywhere to exchange health information?

YesNo

Medical Records (or images) will be sent by Fax, Mail, Carelink, CareEverywhere

Patient information:

Enter full name.

Patient First Name

Patient Last Name

Birthdate

Legal Sex

MaleFemaleUnknown

Is the patient aware of the referral to the Cancer Center?

YesNo

Is the patient currently admitted in a hospital?

YesNo

Preferred Phone

Phone Type

Street Address

City

State

Zip Code

Is an interpreter needed?

YesNo

Does patient have insurance?

YesNo

Type of insurance

CommercialMedicareMedicaidManaged CareSelf-Pay

Diagnosis Information:

Referring Diagnosis

Other Referring Diagnosis

Reason for Referral

Is this an urgent referral?

YesNo

Confirmed Diagnosis?

YesNo

Diagnosis Method

Select the service(s) requested at the location (please check all that apply)

UM Capital Cancer Center

Diagnostic Imaging

Interventional Oncology

Clinical Trial

Medical Oncology

Surgical Oncology

Radiation Oncology

Screening

Please add any additional notes you would like to relay

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