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Patient Referral Form

Connect Your Patient with a Blood Cancer Information Specialist

The Leukemia & Lymphoma Society (LLS) wants to help provide your patients with additional resources and information about blood cancer. By completing LLS’s Patient Referral Form, your patient will be contacted by an LLS Information Specialist. Information Specialists are highly trained oncology social workers and nurses who provide personalized support to patients, caregivers and families.

Complete the Patient Referral Form-English

Complete the Patient Referral Form-Spanish


If your organization’s existing HIPAA authorization form does not cover this request, below is a draft HIPAA Authorization form for your consideration and/or use that you may print, have your patient complete, and then maintain for your own records.