Universal Referral Form
Referred BY Supervising MD Phone: Fax:
Referred TO: Fax #:
Office Address: Phone #:
Patient Name DOB: Gender: F / M
Parent’s Name (if patient is a minor)
Home Phone: Work Phone: Cell Phone:
Authorization: □ Not Required □ Requested/Pending □ Requested/Obtained Auth #
Primary Medical Insurance: Subscriber ID#:
Secondary Medical Insurance: Subscriber ID#:
Worker’s Comp Insurance (if any): Employer:
Adjustor Claim # Date of Injury:
Comp Address Comp Telephone
For Urgent Referrals (need to be seen within a week), the referring clinician should call the specialist.
□ Reason for Referral (Symptoms of Concern) (also send related medical records or dictated summary)
□ Please advise on the patient’s care □ Please assume care of this patient
Please ask patient to provide related records from other specialists, if any.
□ Relevant lab tests and imaging results (also send related medical records)
□ Medications and Dosages tried and outcomes (if not specifically noted in medical records sent with referral)
Please ask patient to bring his/her complete medication list with dosages (or bring the meds themselves) to their appointment.
Appointment is scheduled with: on at arrival time
Prior to appointment please obtain the following information, tests, etc: Date faxed to referring clinician:
□ We will contact patient to schedule □ Please have patient call to schedule □ Please call patient to schedule