Online Physician Referral Request Form

Please note: The form provided below is for use by physicians, their office representatives and  other care providers  who wish to refer a patient to UTMB. Information provided via this form is transmitted securely. Contact information collected via this form is used expressly to serve our referring physicians and their patients. If you wish to refer an unsponsored patient for consideration, please visit this page...  

To make a Radiology Referral, visit here...  

* = required field

Referring Provider Information:

*
*
*
* 
(xxx-xxx-xxxx) 
* 
(xxx-xxx-xxxx)
*
*
*
*
*
 *
 

Patient Information:

*
*
* 
(mm/dd/yyyy)
* Male Female
* 
(xxx-xxx-xxxx)
 
(xxx-xxx-xxxx)
*
*
*
*

Insurance Information: *

 *

Commercial Insurance

Medicare Replacement Plan

Managed Care

Medicare

Medicaid

Self Funded **

  

**Self funded patients receive a 20% discount, and will be expected to pay all estimated patient fees at the time of service.

Physicians: Contact us for assistance

If you are a care provider and would like to speak with someone at UTMB about a patient referral, please contact Faculty One Call: (800) FACULTY (322-8589)


Read more about our services:

To send in a request via FAX or U.S. Mail,

 

 
 

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