Are you the patient's PCP?*

Referring provider information


Patient information

Interpreter needed?
Language

Worker's Compensation

Is this insurance claim work related? *

Insurance/authorization information

Insurance information attached?*
Does the subscriber have a secondary insurance?

Consultation request information

Attachments

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.