Download and use this form as an Uniform Consultation Referral
Uniform Consultation Referral Form
Text Version of the Form
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Uniform Consultation Referral Form
Date of Referral: Carrier Information:
Name:
Patient Information:Name: (Last, First, MI) Address:
Date of Birth: (MM/DD/YY)
Phone #: ( )
Member #: Phone #:
Site #: Fax #:Primary or Requesting Provider:
Name: (Last, First, MI) Specialty:
Institution/Group
Name: Provider ID# 1:
Address: (Street #, City, State Zip)
Phone #: ( ) Fax #: ( )Consultant/Facility Provider:
Name: (Last, First, MI) Specialty:
Institution/Group
Name: Provider ID# 1:
Address: (Street #, City, State Zip)
Phone #: ( ) Fax #: ( )Referral Information:
Reason for Referral:
Brief History, Diagnosis, and Test Results: (Include ICD-9)Services Desired: Provide Care as indicated: Place of Service:
o Initial Consultation Only o Office
o Consult and Treat o Outpatient Medical/Surgical Center*
o Diagnostic Test: (specifiy) __________________ o Radiology
o Consultation with Specific Procedures (specify) o Laboratory
_______________________________________ o Inpatient Hospital*
o Specific Treatment: _______________________ o Extended Care Facility*
o Global OB Care and Delivery o Other (Explain)
o Other: (Explain) *(Specific Facility Must be Named)
Number of Visits: ___ Authorization #: (If required) Referral is Valid Until: (MM/DD/YY) _____________
If Blank, 1 visit is
Assumed (See Carrier Instructions)
Signature: (Individual completing this form) Authorizing Signature: (If Required)