Refer a patient

Thank you for choosing to refer your patient to us. To start the referral process, please fill out this form. If you require additional assistance, please call (800) 444-2559 and ask for either the UCSF Department of Urology or the Physician Liaison Service. If you are unable to fill out this webform or would prefer to fax in your preferral, please fill out and fax the form on the UCSF Make A Referral page.

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UCSF practice: *

Referring Physician Information

Referring MD: *

Specialty: *

Phone: *

Fax:

PCP name: *

PCP phone: *

Your information (if different from above)

From: *

Title: *

Phone *

Fax:

Patient Information

Name of patient: *

DOB: *

Month

Day

Year

Interpreter needed: *

Yes

Language: *

Home phone:

Cell phone:

Work phone:

If child, name of parent:

Address: *

City: *

Zip: *

Insurance:

Include patient's insurance card (both sides) and HMO authorization if required.

Additional page:

Consultation Request Information

Diagnosis/ICD-9: *

Name of UCSF MD (if known):

Specialty:

Reason for consultation:

By providing the information requested and checking this box, you agree that we may initiate treatment following consultation or perform medically necessary diagnostics, in association with this consultation: *

I agree.

Leave this field blank

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