VA-NCI Center for Cancer Research Partnership Provider Referral Inquiry

Welcome to the Veteran's Administration (VA) referral page.

Please use the following form to explore clinical trial options for your patient.
Do not include the date of diagnosis or any patient identifying information on the webform.
The completed form will be sent to the NCI referral office, which will contact you to collect additional patient information. This information will be directed to the appropriate NCI physician.
A response will be sent within 24 - 48 hours to the referring provider listed on the form.

Any questions about the form, process or response time may be directed to the Referral Office via phone 1-888-624-1937 or email Refermypatient@mail.nih.gov.

Medical Information

Diagnosis

Brief summary of patient's disease course

Please include the current disease state, sites of metastatic disease, and date of last treatment.

Does the patient already have other health issues or other cancers?

Yes

Specify other health issues or other cancers:

Is the patient interested in a specific trial?

Yes

If so, please provide name or NCT number

Disease Specific Information

Has the patient had HLA typing?

Yes

Provider Information

Referring Provider Name

Phone Number

Fax Number

Please provide any additional information:

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VA-NCI Center for Cancer Research Partnership Provider Referral Inquiry