Your Consent

Cell Therapy 360 is here to help you get referred to a CAR T cell therapy consultation through our online referral form.

Patient Information

Tell us a bit about yourself.

Oncologist Information

Tell us a bit about your primary oncologist.

Treatment Center

Search and select up to 3 treatment center locations.

Benefits Investigation and Consultation Support

Our support team can look into your insurance benefits, as well as provide support in scheduling a consultation.

Final Review

Referral Request

  • Step 1 Patient Consent Start with a signed patient consent form.
  • Step 2 Patient Information Tell us about yourself to start this referral.
  • Step 3 Oncologist Information Tell us about your oncologist.
  • Step 4 Treatment Center Search and select up to 3 treatment center locations.
  • Step 5 Benefits Investigation and Consultation Support Cell Therapy 360 can perform a benefits investigation request within 48 hours and help you schedule a consultation with the treatment center selected to help avoid access hurdles if initiating treatment.

The decision to refer a patient, and the selection of a particular certified CAR T cell therapy treatment center, is made solely by the referring provider and the patient. Only a certified CAR T cell therapy treatment center can decide if CAR T cell therapy is the appropriate treatment choice for a patient.

Patient information

Please provide some basic information about yourself.

Gender:
Confirm diagnosis:

CAR=chimeric antigen receptor; R/R=relapsed/refractory.

Primary oncologist information

Optionally, please provide who you see for cancer treatment and management. What you fill out is for Bristol Myers Squibb informational purposes, and your primary oncologist will not be contacted unless you request us to.

CAR=chimeric antigen receptor.

Search CAR T cell therapy treatment centers. Add up to 3 treatment center locations, in order of your preference.

0/3 selected

Location 1 00 First Street
Phoenix, AZ 85054
Add

CAR=chimeric antigen receptor.

Benefits Investigation
Understanding your CAR T cell therapy insurance coverage can help provide important information before your CAR T cell therapy consultation.

We’ll look into potential coverage and copay details—results are typically available within 24-48 hours. The final benefits determination will be performed by the CAR T cell therapy treatment center.

Consultation Support
A Cell Therapy 360® Patient Support Navigator can contact you directly and assist with scheduling a CAR T cell therapy consultation with your treatment center of choice.

To Note: The Cell Therapy 360 Patient Support Navigator will only assist with scheduling a CAR T cell therapy consultation. No additional patient support is offered as part of the referral process.


To continue, make a selection:

Primary insurance

Please provide your insurance information by either uploading images of the front and back of your insurance card or filling out the form below.

For questions about insurance or if you do not have insurance, call 1-888-805-4555 for assistance.

Upload a copy of your insurance card (photo or scan)

Card Front

Card Back

Cancel

OR

Fill out the following form:

Add secondary insurance Remove secondary insurance

Secondary insurance

CAR=chimeric antigen receptor.

Final Review

  • Patient Consent
  • Patient Information
  • Oncologist Information
  • Treatment Center
  • Benefits Investigation
  • Consultation Support

Your referral is ready to send.

Submit

BMS values your privacy. BMS, its affiliates, and its agents will not sell or rent your personal information. By providing your information, you acknowledge that you have read and agree to BMS’s Privacy Policy.

CAR=chimeric antigen receptor.

Referral Request Sent! Thank you.

Your CAR T cell therapy referral request has been submitted.

A Patient Support Navigator will reach out to provide the information you requested.

Download your completed referral form

Interested in resources to support the CAR T cell therapy journey?

Explore Patient Resources

CAR=chimeric antigen receptor.

The decision to refer a patient, and the selection of a particular certified CAR T cell therapy treatment center, is made solely by the referring provider and the patient. It is the referring provider’s responsibility to follow all legal and institution requirements for such referrals. Only a certified CAR T cell therapy treatment center can decide if CAR T cell therapy is the appropriate treatment choice for a patient.