For Referring Providers

To better evaluate and collect information, please provide the following:
Please include a patient face sheet (complete with patient name and demographics). Our team reviews all insurance plans to understand their capabilities and plan for possible limitations regarding second opinions and clinical trial considerations. Therefore, our coordinators request that the referring team also send us a copy of the patient’s insurance card.

Please complete and return the Leukemia checklist (Advanced Leukemia checklist PDF), including all relevant pathology reports, imaging reports, and any other pertinent clinical notes. Additionally, kindly fill out the release of information form.

Mailing address for medical records & CDs:
Advanced Leukemia Program
Ann & Robert H. Lurie Children’s Hospital of Chicago
225 East Chicago Avenue, Mailbox #30
Chicago, Illinois 60611
Tel: 312.227.7842 Fax: 312.227.9756

Forward Slides 
ATT: Shunyou Gong
Ann & Robert H. Lurie Children’s Hospital
225 East Chicago Avenue, Mailbox #17
Office: 312.227.3950

We are available Monday through Friday from 8:30 a.m. to 4 p.m. Please feel free to contact us by phone or email at 312.227.7842 / Advanced_Leukemia_Program@luriechildrens.org with any questions.