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Referral Form for Physicians

Thank you for referring your patient to UK HealthCare. Please fill out and submit the secure form below to begin the referral process.

After you submit this form, you will receive a phone response within 24 hours, excluding weekends and holidays.

You may also refer patients by phone by calling UK-MDs at 859-231-9922 or 1-800-888-5533 or by printing and faxing this form to 859-323-4607.


PATIENT INFORMATION  (*Required Fields)
First name: *     Middle Initial: 
Last name: *  
Date of birth: * / / (mm /dd/yyyy)    
Gender: *
What is the patient's primary language?
Does the patient need an interpreter?
   
If patient under 18, Parent / Guardian name: 
  
Patient mailing address
Address line 1:
Address line 2:
City:
State:
Zip code:
Primary phone: * (000-000-0000)      
Alternate phone: (000-000-0000)  
Other comments:  
Insurance provider:

REFERRAL INFORMATION (*Required Fields)
Diagnosis date: * / / (mm / dd / yyyy)
Current treatment: *  
Request a specific physician:
Service or treatment needed:
Preferred location:
Primary diagnosis: *
 
Onset of symptoms and course of illness:
Medications and/or treatment: *
 
Hospitalizations, ER Visits, other info:

REFERRING PROVIDER INFORMATION (*Required Fields)

First name: *   Middle Initial:   
Last name: *    
Primary phone:    
Fax:    
E-mail address: *    
Admin contact:  
Office mailing address
Address line 1:  
Address line 2:  
City:  
State:
Zip code:
All e-mail referral forms will receive a phone response within 24 hours hours excluding weekends and holidays. If you do not receive a response in 24 hours, please call us at (800) 888-5533 or in Lexington (859) 231-9922.
UK-MDs respects the confidentiality of your personal information and promises only to use it for internal purposes as it relates to this request. By submitting this form, you will transmit your details to us safely over a 128-bit encrypted secure network.