Refer a Patient

Important: This form is intended for healthcare providers to make referrals. If you a patient, caregiver, relative, or friend of the patient, please use our Request an Appointment Form.

Instructions

  • Please complete and submit the HIPPA-compliant secure form below. 
  • Physician Referral and Health Insurance Authorization are required. Please fax these to (415) 353-2669
* indicates required field

Patient Information

 
* First Name:
  
* Last Name:
 
* Address:
  
Apartment/Suite No:
* City:
  
* State:
  
* Zip / Postal Code:
  
* Country:
 
* Daytime Phone No:
 
Alternate Phone No:

Email Address:
* Date of Birth:

Example: 02/20/1980
 
* Gender:
 
How did you hear about UCSF?

Referring Provider Information

* First Name:
  
* Last Name:
 
* Address:
  
Office Suite No:
* City:
  
* State:
  
* Zip / Postal Code:
  
* Country:
  
* Office Phone No:
   
Office Fax No:
Cell Phone No:
Pager:
Email Address:

Primary Care Physician Information

* Are you the Primary Care Physician?

If no, please provide the following information (if known).

Name of Primary Care Physician:
Primary Care Physician's Phone:

Insurance Information

Select the patient's medical plan from the dropdown list. If not listed, type the plan into the box “Other”.
* Medical Plan:    
Other:
Group No:
Subscriber No:
Does the patient have secondary or supplemental health insurance?
*Secondary Medical Plan:    
Other:
Group No:
Subscriber No:
* Does the patient have a physician referral?
 

Type of Visit

* Please check all that apply.  


  Other:

Reason For Appointment

* Please indicate the nature of the patient's medical issue or problem below.   

Desired Physician or Provider

If the patient has a physician or provider preference, please make your selection here.

Desired Physician or Provider:
Has the patient seen this provider before?

Diagnosis

If applicable, select the patient's diagnosis from the dropdown list. If not listed, then type the diagnosis into the box labeled "Other".
Diagnosis:

Other:

Diagnostic Tests

Please check all tests performed to diagnose the patient's condition.




Other:

Treatment History

* Has the patient ever been treated for this disease/condition?  
If yes, please check all treatments (past or current) that apply.



Other:
If you checked Surgery above, please provide the date of the most recent surgery.
Has the patient ever participated in a clinical trial for this condition?

Additional Information

Please provide any other relevant information about the patient's treatment in the space below.

Please call us at (415) 353-2357 if you have any questions. We will contact you by the end of the next full business day following receipt of the form.

*  Please type the verification characters below into the yellow box and press "Submit". You will then receive a confirmation message on the screen. Please do not press “Submit” more than once.

 


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