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 a secondary insurance?

Attachments

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

Is your facility or office on EPIC electronic health care system and records can be shared to UC Davis Heath via Care Everywhere? *

If your facility is using Epic, we can pull your supporting records in Care Everywhere.

Attachments (Only PDF and JPEG/JPG files are allowed).

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@ucdavis.edu. If you need technical assistance, please email Health Information Management.

Acknowledgement*