Get Ucla Referral Form

The UCLA Referral Form is essential for obtaining hyperbaric oxygen therapy for patients in need. This guide provides clear instructions on how to complete the form online, ensuring a smooth referral process for users.

Follow the steps to successfully complete the referral form online.

1. Press the ‘Get Form’ button to obtain the UCLA Referral Form and open it in your preferred online document editor.
2. Begin by entering the patient's information. Fill out their name, sex, social security number, date of birth, and address in the designated fields. Ensure that all information is accurate to prevent delays.
3. Next, provide the patient's contact information. Enter the home phone, work phone, cell phone, and email address where applicable. This information is important for communication regarding the referral.
4. In the insurance information section, input the insurance name, policy number, group number, and effective date. This data helps verify the patient's insurance coverage for treatment.
5. Complete the clinical information section. Summarize the clinical history relevant to the referral, including any past medical history that may impact the patient's treatment. Clearly outline the desired goals for therapy.
6. Fill in the referring physician's information, including their name, phone number, fax number, and email address. This ensures that the appropriate medical professionals are informed about the referral.
7. Review all entered information for accuracy and completeness before finalizing the form. Ensure that there are no missing fields that could delay processing.
8. After confirming the details, save your changes. Download the form for your records, or print it directly, and share it via fax at (310)267-1542 or email at wchin@mednet.ucla.edu.

Complete your UCLA Referral Form online today to ensure timely processing of patient referrals.