Provider Referral

Please complete the form.

A scheduling coordinator will reach out to the patient within 2 business days.

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Interests/Other Appointments

Interests/Other Appointments *

Demographic Information

Patient Last Name *


Patient First Name *


Patient Middle Name


Patient Date of Birth *

Select a date from the calendar.

Patient Sex *


Patient Address 1 *


Patient Address 2


Patient City *


Patient State *


Patient ZIP Code *


Patient Country


Patient Home Phone *


Patient Evening Phone


Patient Mobile Phone *


Patient Email *



Insurance Information

Insurance


Insurance Policy Number



Medical Information

Diagnosis *


Current Medications *


Referring Provider Information

Provider First Name *


Provider Middle Name


Provider Last Name *


Provider Address 1


Provider Address 2


Provider City


Provider State


Provider ZIP Code


Provider Work Phone



Other Information

Other Information


When would you like to be seen? *



Disclosure: Joslin has adopted the referral designations of the American College of Physicians to provide the best possible patient care and improve communication with providers who refer to Joslin Diabetes Center. It allows Joslin providers to effectively fulfill expectations for referral and treatment. The three designations and definitions are:

    Co-management:
    a. Co-management with shared care (This is Joslin’s default relationship unless otherwise specified at time of referral.)
    b. Co-management with principal care for the disease by the specialty practice

    Consultation: A formal consultation to answer a clinical question or perform a procedure limited to one or a few visits (if need for consultation is immediate, please provide a phone number for urgent follow up in the “Other Information” box above).

    Transfer: Transfer of the established patient with diabetes to the specialty practice for coordination of care as it relates to diabetes and diabetes-related complications (neuropathy, chronic kidney disease of diabetes, diabetes related retinopathy), and only after discussion and agreement between the Joslin provider and PCP/referring provider.

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