Mayo Clinic Complex Care Program Referral (U.S. residents)

Employers, third party administrators (TPAs) or other contracted entities should complete the form below to submit a referral request to Mayo Clinic.

All fields are required unless marked optional.

Patients should not use this form to self-refer to Mayo Clinic. Instead use the patient appointment request form.

Organization & Submitter Information

The organization that employs the submitter of this form.

Preferred Mayo Clinic location

Not all services are available at each Mayo Clinic location. Mayo Clinic Appointment Services will contact the patient and ensure proper triage and scheduling.

Mayo Clinic Specialty Travel Program

Mayo Clinic contracts with a travel agency to provide high-quality, friendly travel services for patients. For a small fee, the travel agency arranges flight and hotel reservations, transportation to and from the airport, and care-related ground transportation. Travel agents are available 24 hours per day, seven days per week for any travel and lodging concerns or changes.

Who is responsible to pay for travel and lodging expenses for this patient?
Will Mayo Clinic patient travel services be used to book any travel arrangements (e.g., flight, ground transportation, lodging)?

What is Mayo Clinic Patient Travel Service?

Patient Information

Has the patient previously received care at Mayo Clinic?

Patient's information should be as it appears on driver’s license or legal documents. For example if patient goes by Bob, but their legal name is Robert, enter Robert.

Perferred phone type
Secondary phone type

Email address may be used for communication directly with the patient.

Sex (legal)

Legal Sex: Legal/Administrative sex is listed on the patient's driver's license and/or other forms of legal identification.

If the patient is under age 16, a parent's name is required.

If the patient is under age 16, a parent's phone number is required.

Patient's parent/guardian phone type
Does the patient need an interpreter?

Insurance Information

If patient does not have insurance enter N/A in the field

Note: Some plans refer to this as member number or subscriber number. If the patient does not have insurance enter N/A in the field.

Error Use only letters. You must enter at least two letters. Numbers and special characters are not allowed.

Error Use only letters or numbers. You must enter at least two characters. Special characters are not allowed.

Is your request for an appointment related to workers' compensation or a liability claim?

ErrorMake a selection.

Reason for Referral

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If you have questions about the completion of this form or the referral process, please contact the Mayo Clinic Complex Care Program by calling 507-266-5290 or email MCCCPI@mayo.edu.