Referring Provider Consult / Referral Form

Referral Priority

Referral priority for incoming referrals

Within 48 hours

Within 1 week

Within 2 weeks

Within 4 weeks

Within 3 months

Requesting a referral within 48 hours?

You have indicated that your patient needs to be evaluated within 48 hours.

Please call our UI Consult line Toll-Free: 800-322-8442 for immediate assistance.

Please have the following information available:

Caller's name and affiliation
Town/city
Department or physician with whom you wish to speak
A brief description of the nature of your request
Patient's name and demographics

Patient Information

First Name

Middle name

Last Name

Previous name (if any)

Date of Birth

Sex/Gender

Male

Female

Street Address (line 1)

Street Address (line 2)

City

State

County

Zip Code

Phone Number

Alternate Number

Email Address

Guardian Information

Full Name of Parent or Guardian

Use "self" for adult

Relationship to Patient

Insurance

Does the patient have insurance?

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 specieal 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

Referral Detail

Care Requested

Consult Only

Evaluate and Treat

All services necessary

Adult or Pediatric Patient?

Adult Patient

Pediatric Patient

For referrals to specialties not listed or any questions about services, please call us at 1-800-777-8442 to assist you.

Adult Department Specialty

Pediatric Department Specialty

Preferred Physician (if applicable)

Reason for Appointment

Medical Records

Records will be sent by

Fax

Referral submitted electronically, steps to send medical records to follow.

Mail

Referral submitted electronically, steps to send medical records to follow.

UI Carelink

Referral submitted electronically

CareEverywhere (Epic users only)

Referral submitted electronically

Referring Provider Consult / Referral Form

Requesting a referral within 48 hours?

Please have the following information available:

Patient and Visitors

Medical Professionals

Employees & Community