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.
Please attach the following documentation using the file upload at the bottom of this form or fax copies to 413-794-2329:
- GFR <20 documentation (if applicable)
- Form 2728 (if applicable)
- Documentation of Health Screenings:
Colorectal screening if >45 years and <75 years
Mammogram within a year of referral for women >45 years – 54 years
Mammogram within 2 years of referral for women >55 years
Cervical cancer screening for all women between 25-65 years (any of the following)
Primary HPV test within 5 years of referral
Co-test (HPV and PAP) within 5 years of referral
Pap test within 3 years of referral
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.
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