Patient Referrals

Referral Form

Thank you for choosing to refer your patient to UChicago Medicine. To start the referral process, please complete and submit the form below. This form will be submitted directly to the office of Neurosurgery. We will then review the information received and call the patient regarding the referral.

• Please attach pertinent medical records, including test results and imaging, that support the consultation.

• Please attach a copy of the patient’s insurance card (both sides) and HMO authorization, if required.

For help referring a patient, call the MHFP at (773) 795-0622.

Patient Information

Patient Name *

Date of Birth *

Parent or Caregiver Name

Phone *

Cell Phone

Home Phone

Work Phone

Address *

Address

City

State/Province

Zip/Postal

Country

Insurance Company

Please check to see if UChicago Medicine is in network with the patient's insurance plan BEFORE referring the patient.

Insurance ID#

Consultation Request Information

Diagnosis *

ICD-9, ICD-10 diagnosis codes (if available), or name of diagnosis

Reason for Consultation *

Symptoms, concerns, etc.

Requested Physician *

Referring Physician Information

Name of Referring Provider *

If this is a self-referral, or not a referral from a physican, please enter "None" in this field.

Specialty

Clinic Address

City

State/Province

Zip/Postal

Country

Office Phone

Office Fax

File Upload

Maximum upload size: 52.22MB

Please upload pertinent medical records, including test results and imaging (CT, MRI, Xray, etc.) that support the consultation. Please also upload a copy of the patient’s insurance card (both sides) and HMO authorization, if required.

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Referral Form

Patient Information

Consultation Request Information

Referring Physician Information

Common Congenital Anomalies