www.ucdmc.ucdavis.edu    
UC Davis for Referring Physicians


Provider Information

** The form fields shaded grey are Required **
 
First Name: Business E-mail Address:
Middle Initial: Re-enter E-mail Address:
Last Name: Professional Designation:
Last 4 SSN: CA Medical Lic. #:
Are you hospitalist?: Yes No
Do you have private or group practice?: Yes No
Select Hospital/Group:

Employer Name:
Employer Address:
Employer City: Employer State:
Employer Zip Code:
Employer Phone: (xxx) xxx-xxxx Employer Fax: (xxx) xxx-xxxx

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Proof of HIPAA Training
   By checking this box I certify that I have completed HIPAA training and understand my privacy and security obligations in accordance with HIPAA and State Laws. HIPAA Training can be completed by viewing this online presentation.