Patient Referral Form

Physician Access Services is UC San Diego Health's single point of access for referrals to specialists and services.

To refer a patient, complete this form or call the Physician Access Line at 855-543-0555.

* Patient name:

Parent or guardian name:
(if patient is under 18)

Address line 1:

Address line 2:

City:

State:

Zip code:

* Daytime phone number:

XXX-XXX-XXXX

Date of birth:

Year - XXXX

Type of referral:

Consultation

Outpatient test or procedure

* Referring provider name:

* Referring provider e-mail:

Referring provider department or specialty:

Office contact name:

Office contact phone:

XXX-XXX-XXXX

Office contact fax:

XXX-XXX-XXXX

Special needs:

Referred to (provider name or specialty):

Brief diagnosis:

Insurance type:

Bill facility fee to:

Bill professional fee to:

Health plan:

Subscriber name:

Health plan ID number:

Subscriber ID number:

Medical group:

Authorization number:

CPT code(s):

* indicates a required field

Health Professionals