Moffitt Cancer Center is dedicated to providing a comprehensive range of medical services to cancer patients. As part of that mission, our Supportive Care Program offers patients assistance with the physical and emotional challenges they may face as they receive a cancer diagnosis and undergo treatment. Our team of supportive care medicine specialists includes psychiatrists, internists, clinical psychologists, and other supportive care professionals who are committed to improving the quality of life of each of our patients.

Our supportive care medicine specialists offer a range of services that can help patients before, during and after cancer treatment. Because Moffitt is a high-volume cancer center and our supportive care team specializes in assisting patients with cancer, we understand the specific emotional, mental and physical challenges that patients experience after receiving a cancer diagnosis. We can provide advanced care planning, palliative care, nutritional counseling, pain management care, integrative medicine services and behavioral medicine services through our Supportive Care Program, ensuring that each patient receives the individualized support he or she needs. All of these services are available to our patients in the same location where they receive any screening services, diagnostic tests and treatments they require, making our supportive care services as accessible and convenient as possible.

If you would like to refer a patient to our Supportive Care Program, you can complete our online form or contact a physician liaison for assistance or support. Our supportive care medicine specialists are often available to meet with patients within a few days of receiving a referral, ensuring our referral times are kept as short as possible.

Supportive Care Medicine Program

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 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:

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 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:

Hospice, Palliative Medicine, and Clinical Psychology Team

You can refer a patient directly to a Supportive Care Medicine Specialist.

Healthcare Professional Referral Form

Patient Information

Patient Insurance Information

Patient Health & Appointment Information

Referring Provider Information

Confirm & Submit Referral

Patient Contact Information

Patient Insurance Information

Patient Appointment Information

Referring Physician Information

Supportive Care Medicine Leadership

Meet the Supportive Care Program Team

Hospice, Palliative Medicine, and Clinical Psychology Team

You can refer a patient directly to a Supportive Care Medicine Specialist.

Healthcare Professional Referral Form

Patient Information

Patient Insurance Information

Patient Health & Appointment Information

Referring Provider Information

Confirm & Submit Referral

Patient Contact Information

Patient Insurance Information

Patient Appointment Information

Referring Physician Information

Supportive Care Medicine Leadership

Meet the Supportive Care Program Team

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