Referring Physician Consult/Referral Form

Patient Information
mm/dd/yyyy
(xxx) xxx-xxxx
(xxx) xxx-xxxx
Guardian Information
Add "self" if patient is an adult
Insurance
mm/dd/yyyy
Select all that apply
Patient's Primary Care Provider
Requesting Provider/Group
Referral Detail
You must call UI Consult at 800-322-8442 to notify UIHC of high priority.
Please include chief complaint/diagnosis and clinical question to be addressed.