UC Davis for Referring Physicians

Staff 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: Date of Birth: (ie 12/31/1999)
  ** only used for identification purposes **
UC Davis Health System - PhysicianConnect Terms and Conditions of Use
    By checking this box I certify that I have read, understood and agree to accept the Terms and Conditions.

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.