Revised - UC Health Oral and Maxillofacial Surgery Referral Form

UC Health Oral and Maxillofacial Surgery Referral Form
Referrals Valid for One Year

All patients are required to have a referral sent to our office before they can schedule with us.
Referring Provider Information
Printed Name

First NameLast NameSuffix
NPI Number
Practice Location Name
Location Address (referring provider)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Direct Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Fax Number
For sending back consult notes/updatesFormat: (000) 000-0000.
Patient Information
Patient Legal Name as on Insurance Card:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Insurance Provider
Subscriber Policy ID #
Group Number
Secondary Insurance Provider
Subscriber Policy ID #
Group Number
Pre-Authorization / Referral Approval Code (if applicable)
Patient Guardian / Power of Attorney
Name

First NameLast Name
Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
PoA Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
*If over 18, please send copy of POA/Guardianship Papers.
Referral Reason
Primary Reason for Referral *
Emergency cases are not accepted via online form. Referring providers must call 513-475-8783 directly to discuss urgent cases with our clinical team.
Emergency Case
Patient being referred for evaluation and extractions of: (tooth chart)
Preferred Provider (Optional)
Preferred Practice Location (Optional)
Clinical Comments / Medical Notes
Please list if patient is wheelchair bound, stretcher or respiratory patient, or if Patient has any other significant medical history to note.
Radiographs
Radiographs (Choose one)
Upload Radiographs

Cancelof
*Radiographs must be properly labeled to include patient name and dob
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UC Health Oral and Maxillofacial Surgery Referral Form

Referrals Valid for One Year

Referring Provider Information

Patient Information

Patient Guardian / Power of Attorney

Referral Reason

Radiographs

Ready to Submit?