Request a Consultation or Refer a Patient

If you would like to request a consultation with the department of neurological surgery at UChicago Medicine or refer a patient, please fill out the form below. We take pride in helping patients navigate our facility’s services, and we will do our best to review your patient’s history to ensure they are seeing the best provider for their condition.

Referral Form

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

Address *
Address
City
State/Province
Zip/Postal
Country
Please check to see if UChicago Medicine is in network with the patient's insurance plan BEFORE referring the patient.

Consultation Request Information

ICD-9, ICD-10 diagnosis codes (if available), or name of diagnosis
Symptoms, concerns, etc.

Referring Physician Information

If this is a self-referral, or not a referral from a physican, please enter "None" in this field.
Clinic Address
Clinic Address
City
State/Province
Zip/Postal
Country
File Upload

Maximum file 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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