Referring Provider - Cancer Consult / Referral Form

Referral Location and Provider

Where is this patient being referred to?

UI Health Care, Medical Center University, Clinical Cancer Center

Cancer services based in Iowa City

Mission Cancer + Blood, a part of UI Health Care

Cancer services based in the Des Moines area

UI Health Care, Bettendorf, Kimberly Road

Cancer services based in the Quad Cities area

Preferred Physician (if applicable)

Patient Information

First Name

Middle name

Last Name

Previous name (if any)

Date of Birth

Legal Sex

Male

Female

Unknown

Street Address (line 1)

Street Address (line 2)

City

State

County

Zip Code

Phone Number

Alternate Number

Email Address

Guardian Information

Is the patient under the care of a parent or guardian?

Full name of parent or guardian

Relationship to patient

Insurance

Does the patient have insurance?

Yes

Is the policy holder the patient?

Yes

Insurance Company

Policy Number

Customer service phone number

Policy Holder's Name

Policy Holder's DOB

Auth number (if applicable)

Special Needs

Does the patient have any special needs

Hearing impairment

Vision impairment

Needs Interpreter

Needs Wheelchair

Other

Please describe other special needs

Please specify language for interpreter

Referring Provider

Facility Name

Provider's First Name

Provider's Last Name

NPI Number

Address (line 1)

Address (line 2)

Zip Code

Primary Phone Number

Alternate Phone Number

Email Address

Fax Number

Medical Records

Records will be sent by

I will be sending all relevant medical records by fax

I will be sending all relevant medical records by mail

I will be using electronic options, such as CareEverywhere and Inteleshare/Ambra to send all relevant medical records

After you select "Submit" the referral will be submitted electronically and you will be re-directed to the Medical Records Submission information.

Referring Provider - Cancer Consult / Referral Form

Patients and Visitors

Medical Professionals

Employees & Community