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Get Uc Davis Health Referral Intake Form 2017-2025
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How to fill out the UC Davis Health Referral Intake Form online
Filling out the UC Davis Health Referral Intake Form is an essential step in the referral process for patient care. This comprehensive guide will help you navigate each section of the form easily and efficiently, ensuring a smooth submission.
Follow the steps to complete the referral intake form successfully.
- Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Begin by indicating if you are the patient’s primary care provider (PCP) by selecting 'Yes' or 'No' in the designated field.
- Fill in the referring provider information, including referral date, name, office contact name, contact phone, office address, and license number.
- Provide patient information such as the patient’s last name, first name, date of birth, gender, social security number, and address. Ensure all fields are completed accurately.
- Enter the insurance information, including the insurance/plan name, group number, subscriber name, and member ID number. Include both primary and secondary insurance details if applicable.
- Complete the consultation request information by specifying the requested specialty, name of the UC Davis provider if known, ICD-10 codes, the reason for the referral, and any specific services requested.
- If applicable, provide worker’s compensation details including whether it is work-related, the carrier name, address, adjuster contact information, date of injury, employer name, and claim number.
- At the bottom of the form, specify who completed the form by entering their name, phone number, fax number, and email.
- Once all fields have been completed, save any changes you made. You may also choose to download, print, or share the form as needed before faxing it to the Physician Referral Center.
Complete the UC Davis Health Referral Intake Form online today to ensure prompt processing of your patient's referral.
To become a patient at UC Davis, you typically need a referral from your primary care provider. They can complete the UC Davis Health Referral Intake Form to initiate the process. Once this form is submitted, you will be contacted by UC Davis to schedule an appointment, opening the door to specialized healthcare tailored to your needs.
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