Is this a self-referral? *
Are you the patient's PCP? *

Consultation request information

Referring provider information

Patient information

Interpreter needed?
Language

Worker's Compensation

Is this insurance claim work related? *

Insurance/authorization information

Is prior authorization required?
Does the subscriber have secondary insurance?

Attachments

Supporting medical records are required. Lack of attached records or Care Everywhere DOS will result in referral denial.

Does your organization use Epic?*
Does your organization use Care Everywhere Referrals Management (CERM)?

Please send referral via CERM to: UCD Incoming Electronic Referrals.

Your supporting records can be pulled via Care Everywhere, please only attach authorization if required.

DIRECT Messaging Coming Soon. please reach out to your local Physician Liaison to express your interest.

Attachment Requirements
  • Only one PDF file (25 MB or smaller) may be uploaded. If you have multiple documents, please combine them into a single PDF before uploading.
  • Attachment file names must NOT include ! @ # $ % ^ & * ( ) - _ + = [ ] { } | \ \ ; : ' " , < > . / ?
  • Attachment file names must be fewer than 255 characters. If unsure, shorten the file name before clicking the Browse button to upload. Do not remove the file extension (e.g., .pdf, .jpeg, .jpg).

This form may contain private, confidential and privileged material for the sole use of the intended recipient. Any reviewing, copying, or distribution of this fax (or any attachments thereto) by anyone other than the intended recipient is strictly prohibited. If you are not the intended recipient, please contact the sender immediately and permanently destroy this fax and any attachments thereto.

Please complete this form and submit your referral by clicking the "Submit referral form" button below. For referral-related inquiries, please contact the UC Davis Health Physician Referral Center at 800-4-UCDAVIS (800-482-3284) or visit the physician referral website. If you need technical assistance, reach out to UC Davis Health IT Enterprise Web Applications through ServiceNow or call the IT Help Desk at (916) 734-4357.

Acknowledgement*