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:

Patient Information:

Gender*
Insurance Information: *

(*If the patient you are referring is unsponsored/has no medical coverage, please visit this page.)

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

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)


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

More: