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Please use the below form to request an insurance referral to a provider outside of the Tufts Medical Center and New England Quality Care Alliance (NEQCA) network. A request cannot be processed without all the necessary information. A request is not a guarantee of approval.

If you would like to learn more about the specialists in our network, please use our Find a Doctor application. You can request an appointment directly with the physician and their office will help facilitate any necessary referrals or, you can contact your primary care physician's office and they will facilitate the referral.

If you have any questions, please call 617-636-4171

General Information

Name of Person Submitting Request

Patient Name

Patient Date of Birth

Medical Record Number

Phone Number

E-mail

Insurance Plan Name

Insurance ID

Tufts MC Primary Care Information

Primary Care Physician Name

Date Last Seen by Primary Care Physician

Referral Information

Specialty Type

Specialist Name

Specialist Location

Specialist NPI

Specialist Phone Number

Specialist Fax

Diagnosis or Reason for Referral to Specialist

Who referred you to this specialist?

Appointment Date

Interpreter Needed?

Language

Comments

Request an Insurance Referral