Self-Referral for Patients and Families

To better evaluate and collect information, please work with your provider to 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.

Alternatively, you can fill out the top contact and preferred language fields on the Advanced Leukemia checklist PDF, return to our team, and we can send the information request to your provider. 

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.

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.