Patient Referral to the Pancreas Transplant Program at Massachusetts General Hospital

To ensure a smooth and expedited intake process:

Please encourage your patient to call Mass General registration at 866-211-6588, Monday-Friday, 8:00 a.m. to 5:00 p.m. ET.

Please submit the secure form below to refer your patient to a provider in the Pancreas Transplant Program at Massachusetts General Hospital. Be sure to submit the following required documents via fax: 617-726-0822.

• Recent endocrinologist visit note with last hemoglobin A1c and c-peptide titer
• 2728 CMS ESRD form (if on chronic dialysis)
• Recent nephrologist visit note, if applicable
• Recent ED discharge summary
• Pertinent test results (e.g., abdominal/pelvic CT scan)
• Insurance information

Incomplete submissions may result in delays.

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