UC Davis for Referring Physicians
Referral intake form (
*
indicates required field)
*
Referral Date:
Referring Provider Information
*
Referring provider's name (Last, First, Degree):
,
---
DO
MD
NP
OD
PA
PhD
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:
---
Female
Male
Unknown
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
Language:
Worker's Compensation
*
Work Related?
YES
NO
*
Carrier Name:
*
Carrier Address:
*
City:
*
State:
*
Zip:
*
Adjuster Name:
*
Adjuster Phone Number:
*
Claim Number:
*
Date of Injury:
*
Employer Name:
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
Recent/relevant typed clinical notes/test results (health history, physical, MRI/CT/X-ray results, etc.)
Copy of Insurance Card if available
Hardcopy of the Insurance authorization (if required)
Generate a fax cover sheet?
YES
NO
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