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Provider Referral Form (for health care professionals only)

The COVID-19 health crisis has affected clinic operations throughout UK HealthCare. Please see our information for referring providers.

UK HealthCare does not offer the COVID-19 vaccine at our outpatient clinics. Vaccinations are being given at a central location at UK’s Kroger Field, following the state of Kentucky’s phased plan. Ask your patients to submit a request for vaccination at They may call 859-218-0111 if they need help filling out the online form.

Thank you for referring your patient to UK HealthCare. Please fill out and submit the secure form below to begin the referral process. If you are a patient, please use our appointment form.

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

Please print this form for your records before you submit it.  

You may also refer patients by phone by calling UK-MDs at 859-257-5522 or 800-888-5533.

Referring Provider Information

Provider Request
Referring Provider Name
Referring Office

Patient Information

Does the patient need an interpreter?
Patient Mailing Address

Referral Information

All e-mail referral forms will receive a phone response within 24 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 secure network.