Make a Referral

For Physicians:
Texas Oncology Physician Referral & Callback Service is for physicians of patients diagnosed with cancer who are interested in treatment offered at Texas Oncology centers.

If you are ready to refer your patient or would like a callback, please complete the requested information and after you have submitted this request, we will begin the referral process or give you a callback.

If after viewing this form, you decide that you would prefer to speak with one of our referral specialists, please call between 9:00 am and 5:00 pm, CST, Monday – Friday:

  • Transplant: 214-370-1500
  • Hematology and Oncology: 888-864-4226

* indicates required information

Referring Physician Contact Information

If you are a Texas Oncology physician,
please select your name from the list:
 

Or type your name here:
* Physician First Name:
* Physician Last Name:
* Physician Phone Number:
   Physician Alternate Phone:
* Physician City:
* Physician State:
   Alternative Email:

   Confirm Alternative
   Email:

* Type of Referral:

   Transplant
  Hematology and Oncology


Consultation is STRONGLY RECOMMENDED to occur during induction therapy; Donor identification if indicated, can be a lengthy process.

I am ready to refer the patient for an appointment.

   Have your scheduling staff ....
   None
   Call the patient directly with an appointment time.
   Call my office contact with an appointment time.
   Contact me with an appointment time.

I would like a callback from a physician to discuss the case.

   Have a physician ....
   None
   Call me immediately by phone.
   Call me next business day by phone.
   Contact me by email. 


Further instructions if required:
The referral process involves several steps beginning with physician communication, followed by verification of insurance benefits and transplant related requirements.

If you would like for our staff to contact your office to collect the necessary demographic information, Please enter your office number below.

If you would like our staff to contact the patient directly please provide the patient information.

  Office Contact Name:
  Office Contact Phone:

Patient Information

* Patient First Name:

* Patient Last Name:
* Birth Date: / /
   Has patient been
   a Texas Oncology
   patient? 		   Yes
  No
   Misys/Account Number:
   Gender:
   Social Security Number:
At the first appointment, patient will be required to present their social security card and driver’s license or other government issued picture identification in order that we may verify that the patient is a resident of the US.

Patient's Contact Information

* Address:
   City:
   State:
   Zip Code:
* Primary Phone:
   Alternate Phone:

 
   Email:
   Confirm Email:

Insurance Information

* Carrier:

 
* Customer Service Phone:  
 
* Customer Service
  Address: 		 
 
   ID Number:



   Group Number:



   Policy Number:



Diagnosis Information

  What type of cancer has
  been diagnosed?


Other Illness: 

  Diagnosis Details:

After completing and submitting this form, one of our doctors or staff will call your office within 3 business days after receiving your request. To get additional information physicians may communicate with colleagues to discuss cases and share aspects of the case without obtaining patient's permission. This is a peer to peer protected activity allowed by HIPAA. However, it would be a courtesy to all involved, if the referring doctor informs the patient that he/she is being referred.