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Please complete this online form on behalf of your patient to begin the scheduling process. Moffitt will contact your patient within 2 business days to schedule an appointment. 

You can also call us:

Patient Appointment Center: 1(888) 663-3488
Hours: Monday-Friday, 7am-6pm and Saturday 8am-12pm ET.

What You'll Need

Whether you call us or complete the online form below, you'll need to have a few things ready:

  • Referring physician or practice information
  • Patient's full name, contact information and date of birth
  • Reason for visit
  • Patient's primary insurance information

 

Healthcare Professional Referral Form

Patient Information

Patient Insurance Information

Is the patient the policy holder?
Policy Holder's Gender
Does the patient have secondary insurance?

Patient Health & Appointment Information

Why is this patient being referred to Moffitt?
What type of treatment might the patient need?
Does the patient have a preferred Moffitt location?

Referring Provider Information

Does your office participate with Moffitt's Strategic Alliances Nurses?

Confirm & Submit Referral

Please fax patient medical records to 813-449-6999

Please fax patient medical records to 813-449-6999

Please fax patient medical records to 813-449-8210

Please fax patient medical records to 813-449-8210

Patient Contact Information 

Patient First Name:
Patient Last Name:
Patient Date of Birth:
Patient Phone Number:
Patient Alternate Phone Number:
Patient Email Address:
Patient Street Address:
Patient State:
Patient Zip Code:

Patient Insurance Information

Patient Primary Insurance: 
Insurance Policy ID Number: 
Is the Patient the Policy Holder: 
Policy Holder First Name: 
Policy Holder Last Name: 
Policy Holder Date of Birth: 
Relationship to Policy Holder: 
Policy Holder Gender: 
Does the patient have secondary insurance? 
Secondary Insurance Plan Name: 
Secondary Insurance Policy Number: 
Patient's Employer: 

Patient Appointment Information

Why is this patient being referred to Moffitt?
Has patient received cancer diagnosis? 
Current Diagnosis: 
What type of treatment might the patient need? 
What type of screening or prevention does the patient need? 
Comments for scheduler: 
Preferred location: 
Moffitt provider referring to: 

Referring Physician Information

Referring Physician First Name: 
Referring Physician Last Name: 
Referring Physician NPI Number: 
Referring Physician Specialty: 
Referring Physician Email: 
Referring Physician Phone Number: 
Referring Physician Alternate Phone Number: 
Referring Physician Fax Number: 
Participate with Moffitt's Strategic Alliances Nursing? 
Full name of contact submitting form: 
Email of contact submitting form: 

Please hit the Submit Your Referral button at the top of the page to send your referral to us!

Patient Contact Information 

Patient First Name: ::PatientFirstName::
Patient Last Name: ::PatientLastName::
Patient Date of Birth: ::PatientBirthdate::
Patient Phone Number: ::PatientPhone::
Patient Alternate Phone Number: ::AlternatePhone::
Patient Email Address: ::PatientEmail::
Patient Street Address: ::PatientAddress::
Patient State: ::PatientState::
Patient Zip Code: ::PatientZip::

Patient Insurance Information

Patient Primary Insurance: ::PatientInsuranceType::
Insurance Policy ID Number: ::InsurancePolicyNumber::
Is the Patient the Policy Holder: ::PatientPolicyHolder::
Policy Holder First Name: ::PolicyHolderFirstName::
Policy Holder Last Name: ::PolicyHolderLastName::
Policy Holder Date of Birth: ::PolicyHolderBirthdate::
Relationship to Policy Holder: ::RelationshiptoPolicyHolder::
Policy Holder Gender: ::PolicyHolderGender::
Does the patient have secondary insurance? ::HaveSecondaryInsurance::
Secondary Insurance Plan Name: ::SecondaryInsuranceType::
Secondary Insurance Policy Number: ::SecondaryInsurancePolicyNumber::
Patient's Employer: ::PatientEmployer::

Patient Appointment Information

Why is this patient being referred to Moffitt? ::ReferredFor::
Has patient received cancer diagnosis? ::ReceivedDiagnosis::
Current Diagnosis: ::MedDiagnosis::
What type of treatment might the patient need? ::TypeOfTreatment::
What type of screening or prevention does the patient need? ::CancerScreen::
Comments for scheduler: ::AnyQuestionsComments::
Preferred location: ::PreferredLocation::
Moffitt provider referring to: ::RequestedMoffitPhysicianName::

Referring Physician Information

Referring Physician First Name: ::ReferringPhysicianFName::
Referring Physician Last Name: ::ReferringPhysicianLName::
Referring Physician NPI Number: ::ReferringPhyNPINumber::
Referring Physician Specialty: ::ReferringPhysicianSpeciality::
Referring Physician Email: ::ReferringPhysicianEmail::
Referring Physician Phone Number: ::ReferringPhysicianPhone::
Referring Physician Alternate Phone Number: ::ReferringPhysicianAlternatePhone::
Referring Physician Fax Number: ::ReferringPhysicianFax::
Participate with Moffitt's Strategic Alliances Nursing? ::MoffittStrategicAlliance::
Full name of contact submitting form: ::FullNamePersonCompletedForm::
Email of contact submitting form: ::EmailPersonCompletedForm::

Please hit the Submit Your Referral button at the top of the page to send your referral to us!