ICU Recovery Clinic Referral Form

Thank you for your referral to the UK ICU Recovery Clinic. Please review the criteria for a referral below. We will review your patient’s records and contact you as quickly as possible. Please provide us with the clinical and demographic information we need for review. 

If you have any questions, please contact our offices directly. Referrals will be denied if all of this information is not received.

Patients must exhibit the factors listed below for a physician referral:

  • Admission to the ICU within the last 6 months and have ongoing physical, emotional, and/or cognitive symptoms.

PLUS any of the following diagnoses during their admission:

  • Mechanical ventilation for longer than 24 hours
  • High flow nasal cannula requirement
  • Acute respiratory distress syndrome
  • New Tracheostomy
  • Shock requiring vasopressor support for greater than 72 hours
  • Myopathy of critical illness
  • Delirium
  • Mechanical circulatory support or VV-ECMO for respiratory failure
Dates of ICU Stay
more items
Facility Address
You can also attach a medication list to the referral.
Company, plan, group

Referring Physician Information

Referring Physician Address
Please list name and phone number.

Required documentation from referring physicians: recent reports for CT scans of chest or chest imaging, discharge summary from hospitalization, medication list, and most recent office note and copy of insurance card.

Maximum 3 files.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.