UW MEDICINE Referral Request
PT.NO
NAME
DOB
UW Medicine
Harborview Medical Center – UW Medical Center
Northwest Hospital & Medical Center – University of Washington Physicians
Seattle, Washington
UW MEDICINE REFERRAL REQUEST
*U2394*
*U2394*
WHITE – MEDICAL RECORD
UH2394 REV NOV 11
Thank you for referring your patient to UW Medicine. This form is to be completed by the outside referring provider or designee.
For information about making referrals and/or to complete this form online and print it out go to: http://uwmedicine.org/referrals. A list
of UW Medicine clinics and providers can also be accessed on the same web page. Note: UWP Physicians use UH2460.
Patient Name (Last Name, First Name, Middle Initial)
Date
Gender Male Female
Patient preferred language for healthcare communication
Date of Birth Patient Home Telephone
Patient Alternative Telephone
Patient Home Address
Patient insurance company and plan(s)
Referral From:
Referring Provider Name (Last Name, First Name, Middle Initial)
NPI
Referring Provider Contact Telephone Referring Provider Fax
Referring Provider Address
Patient’s Primary Care Provider (Last Name, First Name, Middle Initial)
Referral To:
Specialty Clinic Name
Clinic Location
Provider Name
Referral/Urgency Routine
Urgent
Emergent: referring Provider must call consulting Provider for emergent referrals
Reason for Referral:
Consultation (Diagnosis/Treatment/Surgical Opinion)
Transfer of Care (Indicate condition or problem the specialist is being asked to manage)
Reason for request; include diagnosis:
Provider Signature
