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

Referral intake form (* indicates required field)
* Referral Date:


Referring Provider Information
* Referring provider's name (Last, First, Degree):
,  
Referring provider's email:
License Number: * NPI Number: * Primary Specialty:
* Office contact name (Last, First):
* Office contact phone:
* Office contact email:
Office address: Office Phone: Office Fax:
City: State: Zip:
Patient Information
* Patient Last Name: * Patient First Name: * Date of Birth: * Gender: SSN:
Address: Home Phone Number (with area code):
City: State: Zip:
* If minor, name of parent/caregiver/guardian. Otherwise, enter N/A: Interpreter Needed: YES NO
Worker's Compensation * Work Related? YES NO
Insurance/Authorization Information
* Insurance/plan name: Group number: Prior authorization number:
* Subscriber name / date of birth / * Subscriber member ID number: Number of visits authorized / expiration date: /
Secondary insurance/plan name: Group number: Prior authorization number:
Subscriber name / date of birth / Subscriber member ID number: Number of visits authorized / expiration date: /
Consultation Request Information
* Requested specialty and name of UC Davis provider (if known)
* Specialty:
UCD Provider Name:
* ICD-10 code(s): ICD-10 code(s): ICD-10 code(s):
* Service requested:
Consultation Second Opinion
* Reason for referral:
Attachment
  1. Recent/relevant typed clinical notes/test results (health history, physical, MRI/CT/X-ray results, etc.)
  2. Copy of Insurance Card if available
  3. Hardcopy of the Insurance authorization (if required)



Generate a fax cover sheet? YES NO
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