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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 813-449-8210

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 page to send your referral to us!