ASH Members
A collaboration between American Society of Hematology (ASH) and The Leukemia & Lymphoma Society’s Clinical Trial Support Center (CTSC) allows ASH member physicians (and their care teams) to initiate the connection between a CTSC Nurse Navigator and their patient by using the ASH portal. When the submission is received, a CTSC Nurse Navigator will contact the patient and complete a clinical trial search. We will also communicate our search results with the HCP.
Access the Portal
Non-ASH Members
Please complete the referral form below and select “My Patient" at the top of the form. By completing and submitting this form, you represent you are authorized to share the information of the patient, including the patient's medical information, with LLS. When this form is received, a CTSC Nurse Navigator will contact the patient and complete a clinical trial search. We will also communicate our search results with the HCP.
Complete the Referral Form
HIPAA
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.
