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Referring Physician Consult/Referral Form
Referring Physician Consult/Referral Form
Patient Information
Patient First Name (legal)
*
Patient Middle Name
Patient last Name (legal)
*
Patient Maiden/Former Name (if applicable)
Patient's Birth Date
*
mm/dd/yyyy
Patient's Gender
male
female
Patient's Address Line 1
*
Patient's Address Line 2
Patient's Zip
*
Patient's City
*
Patient's State
*
Patient's Country
Patient's Primary Phone
*
(xxx) xxx-xxxx
Patient's Alternate Phone
(xxx) xxx-xxxx
Guardian Information
Full Name of Parent or Guardian
*
Add "self" if patient is an adult
Parent/Guardian's contact is different from the patient's
Parent/Guardian's Address Line 1
Parent/Guardian's Address Line 2
Parent/Guardian's Zip
Parent/Guardian's City
Parent/Guardian's State
Insurance
Patient's Insurance Carrier
*
Patient's Insurance Policy Number
*
Insurance customer service phone number
*
Policy Holder's Name
*
Policy Holder's Date of Birth
*
mm/dd/yyyy
Patient's Insurance Authorization Number (if applicable)
Has this patient been seen before at University of Iowa Hospitals and Clinics?
Yes
No
Unsure
If Yes, Provide Patient Medical Record Number
Does the patient have any special needs?
Hearing Impaired
Vision Impaired
Needs Interpreter
Needs Wheelchair
Other
Select all that apply
If other, please describe:
Patient's Primary Care Provider
PCP's First Name
PCP's Last Name
PCP's City
PCP's State
Requesting Provider/Group
Facility Name
Provider's First Name
*
Provider's Last Name
*
NPI Number
Address Line 1
*
Address Line 2
Zip
*
City
*
State
*
Primary Phone
*
Alternate Phone
Provider or Group Email
Fax
Referral Detail
Referral priority for incoming referrals
A. Within 48 hours
B. Within 1 week
C. Within 2 weeks
D. Within 4 weeks
E. Within 3 months
You must call UI Consult at 800-322-8442 to notify UIHC of high priority.
Management of care requested
Consult only
Evaluation, testing, and treatment
All services necessary
Physician Requested
Specialty Clinic Requested
*
Reason for Request
*
Please include chief complaint/diagnosis and clinical question to be addressed.
Pertinent Medical Records will be sent by:
*
Fax
Postal Mail
UI Carelink
No Medical Records will be sent
Please leave blank
