Now Taking Physician Referrals Learn more about patient safety precautions, virtual visit options, and referring physician resources. Thank you for referring your patient to University of Utah Health. We value our relationship with referring physicians. Please fill out the form below. Fax applicable records to: 801-587-7290 Office hours: 8 am–5 pm You must have JavaScript enabled to use this form. Referring Provider Information Referring Provider Full name (Last, First) * Referring Provider Email Address * Referring Provider Phone Number * Referring Provider Fax Number Referring Provider NPI Number * Office Address * Office/Clinic Name Referring to Information Would You Like to Request a Specific Provider? No Yes Please provide the name of the specific provider Specialty Department you are referring the Patient to * Preliminary Diagnosis * Reason for Referral * Urgency Rating Urgent 24-hour contact Routine 48-hour Patient Information Full Name First * Middle/Initial * Last * Date of Birth * Gender Male Female Prefer Not to Answer Other Please Specify How the Patient Identifies Full Name of Parent or Guardian (If Minor) (Last, First) Phone Number * Address Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code If Interpreter is Needed, Please Specify Language Insurance Leave this field blank
