UC Davis Health Patient Referral Form
This file contains the UC Davis Health Patient Referral Form, outlining the steps and requirements needed to refer a patient. It includes the necessary fields, instructions, and contact information. This form is intended for non-urgent and urgent referral requests and must be filled out and submitted to UC Davis Health.
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How do I fill this out?
To complete the UC Davis Health Patient Referral Form, you need to provide accurate information about the referring provider, patient, and insurance details. Make sure to include all relevant clinical notes, test results, and authorization information. Carefully follow the instructions provided to ensure the referral process is not delayed.
How to fill out the UC Davis Health Patient Referral Form?
1
Complete the referring provider information section.
2
Fill out the patient information section.
3
Provide insurance and authorization details.
4
Specify the consultation request information.
5
Fax the completed form and supporting documents to 916-703-6048.
Who needs the UC Davis Health Patient Referral Form?
1
Primary care physicians who need to refer patients to specialists at UC Davis Health.
2
Medical professionals seeking a second opinion on a patient's diagnosis or treatment plan.
3
Surgeons who require additional consultations before performing a procedure.
4
Healthcare providers referring patients for diagnostic tests or imaging services.
5
Case managers coordinating care for patients with complex medical conditions.
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PrintFriendly's PDF editor allows you to edit the UC Davis Health Patient Referral Form with ease. You can add, modify, or delete information directly within the form fields, ensuring accuracy and completeness. Our user-friendly editor makes it simple to update referral forms as needed before submission.
1
Open the UC Davis Health Patient Referral Form in PrintFriendly's PDF editor.
2
Enter the required information in the provided fields.
3
Modify or delete any existing information as needed.
4
Save your changes to the form.
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Download or share the edited form electronically.
What are the instructions for submitting this form?
To submit the UC Davis Health Patient Referral Form, complete all required fields and gather the necessary supporting documents. Fax the completed form and documents to the Physician Referral Center at 916-703-6048. For urgent requests, call the Physician Referral Center at 800-482-3284, option #3. Make sure to provide accurate and up-to-date information to avoid delays in processing. It is recommended to double-check all entries and attachments before submission to ensure completeness and accuracy.
What are the important dates for this form in 2024 and 2025?
There are no specific dates for submitting this form for 2024 and 2025. It can be submitted any time when a patient referral is needed.
What is the purpose of this form?
The purpose of the UC Davis Health Patient Referral Form is to streamline the process of referring patients to specialists, ensuring they receive the necessary care and support. This form provides a standardized method for healthcare providers to communicate essential patient information, medical history, and authorization details to UC Davis Health. By using this form, referring physicians can ensure that their patients are promptly assessed and treated by the appropriate specialists at UC Davis Health, reducing wait times and improving overall patient care. Additionally, this form helps to facilitate effective communication and coordination between healthcare providers, ensuring that all relevant information is accurately conveyed and taken into account during the referral process. Utilizing the UC Davis Health Patient Referral Form ultimately contributes to a more efficient, organized, and patient-centric healthcare system.
Tell me about this form and its components and fields line-by-line.
- 1. Referring provider information: Includes the provider's name, office address, license number, primary specialty, and contact information.
- 2. Patient information: Includes the patient's name, date of birth, gender, SSN, contact information, and if applicable, the name of the parent or guardian.
- 3. Insurance/authorization information: Includes details about the patient's insurance plan, subscriber information, group number, and prior authorization details.
- 4. Consultation request information: Includes the requested specialty, ICD-10 codes, service requested, reason for referral, and related workers' compensation information.
What happens if I fail to submit this form?
If you fail to submit the UC Davis Health Patient Referral Form, your referral request may be delayed or denied. This could result in longer wait times for your patients and potential disruptions in their care.
- Delayed referral processing: Incomplete or missing information can cause delays in the processing of the referral, leading to longer wait times for patients.
- Denied referral request: Failure to provide the necessary documentation and authorization information may result in the referral request being denied.
- Disrupted patient care: Delays or denials in the referral process can lead to disruptions in the patient's care and treatment plan.
How do I know when to use this form?
- 1. Specialist consultations: Refer patients to UC Davis Health specialists for further evaluation and treatment.
- 2. Second opinions: Seek a second opinion on a patient's diagnosis or treatment plan from UC Davis Health experts.
- 3. Surgeries: Refer patients for surgical consultations and procedures at UC Davis Health.
- 4. Diagnostic tests: Request diagnostic tests or imaging services for patients needing further evaluation.
- 5. Coordination of care: Ensure coordinated care for patients with complex medical conditions by referring them to UC Davis Health.
Frequently Asked Question
How do I fill out the UC Davis Health Patient Referral Form?
Use PrintFriendly's PDF editor to enter the necessary information in the fields provided. Follow the instructions carefully and include all relevant supporting documentation.
Can I sign the referral form electronically?
Yes, PrintFriendly's signing feature allows you to sign the form electronically using your mouse or touchpad.
How can I share the completed referral form?
You can share the form via email, direct link, or cloud storage using PrintFriendly's sharing options.
What information do I need to provide in the referral form?
You need to provide referring provider information, patient information, insurance details, and consultation request information.
How do I submit the completed referral form?
Fax the completed form and supporting documents to 916-703-6048.
Can I edit the referral form after filling it out?
Yes, PrintFriendly's PDF editor allows you to modify the information in the form fields before saving or submitting it.
What should I do if I have an urgent referral request?
For urgent requests, call the Physician Referral Center at 800-482-3284, option #3.
How long does it take to process a referral?
Please allow up to 48 hours for processing the referral. Incomplete information may delay the process.
What supporting documents should I include with the referral form?
Include recent clinical notes, test results, proof of insurance, and authorization information with CPT code details.
What happens if the information in the referral form is incomplete?
Incomplete information may delay the processing of the referral. Ensure all required fields and supporting documents are provided.
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