Physician Referral Intake Form | Physician Referrals| UC Davis Health

Electronic Referral Intake Form

Is this a self-referral? *

Yes

Are you the patient's PCP? *

Yes

Referral date

Is this an urgent request? *

Yes

Consultation request information

Requested specialty *

Requested specialist

Service requested

Please specify the service

ICD-10 code(s):

Reason for referral

Referring provider information

Last name

First name

Degree

Office email address

License number

NPI number

Primary specialty

Office/facility name

Office contact name

Office contact phone

Office fax

Office address

City

State

Zip

Patient information

Patient last name

Patient first name

Date of birth

If minor, name of parent

Patient/guardian email

Gender

SSN

Phone number

Home

Cell

Phone number

Home

Cell

Address

City

State

Zip

Interpreter needed?

Yes

Worker's Compensation

Is this insurance claim work related? *

Yes

Insurance/authorization information

Subscriber last name

Subscriber first name

Date of birth

Insurance/plan name

Member ID

Group number

Is prior authorization required?

Yes

Prior authorization number

Number of visits authorized

Expiration date

Does the subscriber have a secondary insurance?

Yes

Address*

City*

State*

Zip*

Attachments

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

Does your organization use Epic?*

Yes

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

Yes

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.

Name of your organization or organization hosting your Epic (i.e. OCHIN, Sutter, Hill Physicians, etc.)*

Supporting records date of service*

Attachments (Only PDF and JPEG/JPG files are allowed; attachment file names can not include: < > : " / \ | ? *).

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)

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. You can also print the completed form and submit it via fax to 916-703-6048 or email to hs-referralcenter@health.ucdavis.edu. If you need technical assistance, please email Health Information Management.

Acknowledgement*

By checking this box, I acknowledge that all referrals are reviewed for medical necessity and service line capacity. Submission of referral is not a guarantee of acceptance. To check the status of your referral or ask questions post-confirmation, please contact the specialty department.

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