Karmanos Patient Referral Form | Karmanos Documents and Links

We value the confidence you place in the Barbara Ann Karmanos Cancer Institute when you refer your patients to us for cancer care. To make it as easy as possible for you to refer your patients to our NCI-designated comprehensive cancer center, please fill out the form below and a Karmanos representative will respond to your request as soon as possible.

*Indicates required information

Refer a Patient

Patient Name: *

Patient Birth Date: *

Patient Address: *

Patient City: *

Patient State: *

Patient Zip Code: *

Patient Phone Number: *

Physician Information

Referring Physician Name: *

Referring Physician Phone Number: *

Referring Physician Address (Name of Practice or Healthcare System): *

Referring Physician City, State, Zip Code: *

Referring Physician Email Address:

Type of specialist you would like to refer your patient to (ex. Surgeon, Radiation Oncologist, Medical Oncologist, etc.): *

Name of physician you would like to refer your patient to:

Reason for referral or diagnosis: *

Can Karmanos contact your patient directly? *

Yes

Name of Insurance:

Insurance Contract Number:

Insurance Group Number: