REFERRAL FORM - UCSF Health
REFERRAL FORM
Thank you for choosing to refer your patient to UCSF. To start the referral process, please complete this form and fax it directly to the clinic.
n To find a clinic fax number, search at refer-a-patient. n Send brief, pertinent medical records, including test results and imaging, that support the consultation. n Send a copy of the patient's insurance card (both sides) and HMO authorization if required. n For help referring a patient, call (800) 444-2559.
Date No. of pages To UCSF practice Fax
From Title Phone Fax
PATIENT INFORMATION
Name of patient DOB Home phone Parent or caregiver Address City Insurance
q Work phone q Cell phone
State
Zip
C O N S U LTAT I O N R E Q U E S T I N F O R M AT I O N
Diagnosis/ICD-9/10
Name of UCSF MD (if known)
Specialty
Reason for consultation
By providing the information requested and signing below, you agree that we may initiate treatment following consultation or perform medically necessary diagnostics in association with this consultation. We look forward to collaborating with you on your patient's treatment plan.
REFERRING PHYSICIAN INFORMATION
Referring MD Phone Primary care provider Signature
Specialty Fax Phone
NOTICE OF CONFIDENTIALITY: This is a confidential fax and is intended solely for the person indicated above. If you are not the intended person, you are hereby notified of the confidential nature of this fax and that you are not entitled to read, copy or otherwise disseminate any of the information contained herein.
Form updated: October 2019 ? Made accessible October 2022
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