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 Information

XXX-XXX-XXXX
Year - XXXX

Referring Provider Information

XXX-XXX-XXXX
XXX-XXX-XXXX

Billing and Insurance Information

* indicates a required field