Karmanos Cancer Institute at McLaren Flint Referral Form

We value the confidence you place in the Barbara Ann Karmanos Cancer Institute at McLaren Flint 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 cancer center, please fill out the form below and a Karmanos representative will respond to your request as soon as possible.

*Indicates required information

Referred By *

Physician Referral

Self Referral

Branch you would like the patient to be evaluated (if applicable) *

Patient Phone Number: *

Best time to call: *

Primary Physician:

Primary Physician Office Phone:

Referral Information

Diagnosis/reason for referral: *

Previous diagnosis of cancer:

Previous radiation treatment

Yes

Specialist Phone:

Physician Requested:

Patient Insurance Information

Insurance Group Number: *

Contract Number:

Referring Physician Information

Referring Physician Name: *

Referring Physician Address: *

Referring Physician City, State, Zip Code: *

Referring Physician Phone Number: *

Referring Physician Office Fax *

Additional Information Needed

Pathology report (path slides will need to be requested**)

Most recent scans – CT, PET, MRI, Bone Scan, etc. on CD in DICOM format along with reports**

All labs

Chart Notes

Previous cancer treatment including chemotherapy flow and/or radiation flow sheets

Surgeon/Medical Oncologist/Radiation Oncologist name and contact information, if applicable

**If Karmanos Cancer Institute at McLaren Flint and/or the McLaren Proton Therapy Center receives a signed Authorization to Release Medical Records form from the patient, we can request these items on the patient’s behalf.

Self-Referral: How did you hear about Karmanos Cancer Institute at McLaren Flint/McLaren Proton Therapy Center?

Physician Radio Friend or Family Member
Newspaper or Magazine Mail Online Ad
Internet Search Billboard McLaren/Karmanos Website
Community Event or Seminar Social Media TV-News
Other

If you selected other, please specify:

Medical Oncology	Surgical Oncology
Radiation Oncology	Proton Therapy
Gynecologic Oncology

Karmanos Cancer Institute at McLaren Flint Referral Form

Refer a Patient

Patient Information

Referral Information

Patient Insurance Information

Referring Physician Information

Additional Information Needed

Physician	Radio	Friend or Family Member
Newspaper or Magazine	Mail	Online Ad
Internet Search	Billboard	McLaren/Karmanos Website
Community Event or Seminar	Social Media	TV-News
Other