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Referring Physician Consult/Referral Form
Referring Physician Consult/Referral Form
Referral Priority
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
Patient Information
Has patient been seen here before?
Yes
No, or unsure
MRN, if available
First name
*
Middle name
Last name
*
Previous name (if any)
Date of Birth
*
mm/dd/yyyy
Sex/Gender
Male
Female
Street Address (line 1)
Street Address (line 2)
Zip Code
Phone Number
*
(xxx) xxx-xxxx
Alternate Number
(xxx) xxx-xxxx
Email address
Guardian Information
Full Name of Parent or Guardian
*
Use 'self' for adult
Relationship to Patient
*
Insurance
Insurance Company
*
Policy Number
*
Customer service phone number
*
Policy Holder's Name
*
Policy Holder's DOB
*
mm/dd/yyyy
Auth number (if applicable)
Special Needs
Does the patient have any special needs?
Hearing impairment
Vision impairment
Needs Interpreter
Needs Wheelchair
Other
Select all that apply
Please specify language for interpreter
Please describe other specieal needs
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
Preferred Physician or Department Specialty
*
Reason for Appointment
*
Medical Records
Records will be sent by:
*
Fax
Mail
UI Carelink
CareEverywhere (Epic users only)
No Medical Records will be sent
Please leave blank
