Get Universal Referral Form - University Of Washington - Rehab Washington

The Universal Referral Form for UW Medicine is designed to facilitate referrals from outside providers to various specialty clinics within the University Of Washington system. This guide will assist you in completing the form accurately and efficiently to ensure a seamless referral process.

Follow the steps to fill out the Universal Referral Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. In the 'Patient Name' section, enter the patient's last name, first name, and middle initial.
3. Select the patient's gender by marking either 'Male' or 'Female'.
4. Enter the patient's date of birth in the designated field.
5. Indicate the patient’s preferred language for healthcare communication.
6. Provide the patient’s alternative phone number and home telephone number.
7. Fill in the patient's home address in the corresponding section.
8. Document the patient’s insurance company and plan(s).
9. In the 'Referral From' section, input the referring provider's name, contact telephone number, NPI, fax number, and address.
10. Enter the name of the patient’s primary care provider in the specified field.
11. In the 'Referral To' section, indicate the specialty clinic name and specify the urgency of the referral as 'Routine', 'Urgent', or 'Emergent'.
12. State the reason for the referral, choosing between 'Consultation', 'Transfer of Care', and providing any additional information as necessary.
13. Provide the referring provider's signature where indicated and ensure it is printed clearly.
14. Finally, save your changes, and you may choose to download, print, or share the completed form as needed.

Complete your referral request online today to streamline the process!