Physician Referral Form - Keck Medicine of USC

1
Referring Physician Contact* This field is required.Tell us about yourself.
Physician Name
Practice Name
Physician Email
Physician Phone Number
NPI Number (Required for Domestic Patient)
2
Referring Physician Practice InformationHow may we reach you?
Physicians Office Address
City
State (Required for Domestic Patient)
Zip Code (Required for Domestic Patient)
Fax Number
3
Patient Insurance Information* This field is required.To help expedite the referral, provide the patients details below
Patient Insurance Provider
Patient Insurance Provider ID
Yes
No
Does patient have HMO Insurance (Attachment of Prior Authorization will be required if yes)?
4
Attach Prior Authorization* This field is required.This is required for patients with HMO Insurance
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Max. file size: 10.6MB
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5
Patient Contact DetailsTell us about the patient you are referring.
Patient Name (Last, Middle, First)
Male
Female
Non-binary
Gender
Birth Date (MM/DD/YYYY)
Language Preference
Patient Phone Number
Patient Email (Optional)
Primary Care Physician (Optional)
6
Is this patient a minor (under the age of 18)?* This field is required.
YESNO
7
Parent/Guardian Information* This field is required.If this patient is a minor, please provide the following details:
Parent/Guardian Name
Parent Guardian Phone Number
8
Additional Patient Contact Details
Address
City
State
Zip Code
Country (Required for international patient)
Emergency Contact
9
Appointment Request
Clinical question to be answered. Attachments of any pertinent medical records will be required.
Indication or Diagnosis
Bariatric Surgery
Cancer (Oncology)
Cardiology
Cardiothoracic Surgery
Dermatology
ENT (Otolaryngology)
Family Medicine
Gender Affirming Care
General Internal Medicine
General Surgery
Heart Surgery (Aortic/Cardiac Surgery)
Hepto Surgery
Infectious Disease
Nephrology
Neurosurgery
Orthopaedics
Pain
Plastic & Reconstructive Surgery
Psychiatry
Pulmonary
Rheumatology
Spine
Thoracic Surgery
Transplant
Urology
Vascular Surgery
Women's Health
Other
Specialty Requested
Specific Physician Requested (Optional)
10
What is the associated radiology procedure?Please select all that apply.
XR Chest 1 View
XR Abdomen 1 View
XR Chest 2 Views
CT Head or Brain w/o Contrast
MA Digital Mammo Screening
CT Chest w/ Contrast
CT Abdomen and Pelvis w/ Contrast
CT Chest w/o Contrast
XR Chest 1 View Portable
US Abdomen Complete
MRI Brain w/ + w/o Contrast
CT Abdomen and Pelvis w/o Contrast
US Retroperitoneal Complete
XR Fluoro Spine
MA Digital Mammo Diag Bilateral
XR Spine Lumbar 4 Views-Complete
XR Shoulder Complete Right
XR Spine Lumbar 2 views
MRI Brain w/o Contrast
XR Shoulder Complete Left
US Pelvis Trans-Abdominal/Endovaginal
US Abdomen Ltd/Quad/Fu (Please Specify)
BD DEXA Axial Skeleton
US Abdomen Complete with Doppler
US Head/Neck Soft Tissue
XR Fluoroscopy Up to 1 Hour
CT Abdomen and Pelvis w + w/o Contrast
XR Foot Complete Right
MRI Spine Lumbar w/o Contrast
XR Foot Complete Left
US Breast Limited Left
XR Knee Complete Bilat
PET Body - Skull Base to Mid Thighs
Top Orders by Volume
XR Spine Cervical 2 Views
XR Knee Complete Right
US Breast Limited Right
XR Pelvis 1 or 2 Views
XR Knee Complete Left
XR Ankle Complete Right
CT Angiography (CTA) Head w/ + w/o contr
CT Angiography (CTA) Abd/Pelvis w/ + w/o
XR Ankle Complete Left
XR Hip Bilateral w/Pelvis 3V
US Paracentesis Initial
XR Chest 1 View Post Procedure
XR Knee 3 Views Right
CT Angiography (CTA) Chest w Cont PE Stu
MRI Spine Cervical w/o Contrast
XR Knee 3 Views Left
XR Spine Cervical Complete
CT Angiography (CTA) Chest/Aorta w/ + w/
XR Bone Length Studies Scanograms
MRI Abdomen w/ + w/o Contrast
XR Hip 2 Views Right
XR Knee 1 or 2 Views Right
XR Knee 3 Views Bilat
XR Spine Scoliosis AP/Lat
XR Wrist Complete Left
XR Hip 2 Views Left
XR Wrist Complete Right
XR Knee 1 or 2 Views Left
XR Hand Complete Right
XR Hip RT w/ Pelvis 2-3 Views
XR Hip LT w/ Pelvis 2-3 Views
CT Soft Tissue Neck w/ Contrast
MRI Prostate w + w/o Contrast w Glucagon
XR Hand Complete Left
Top Orders by Volume
CT Angiography (CTA) Neck w/ + w/o contr
US Scrotum/Testicular w/ Doppler
IR Angio Carotid Cerv/Cereb
MA Digital Mammo Diagnostic Left
XR ERCP Biliary and Pancreatic Duct
CT Spine Cervical w/o Contrast
MA Digital Mammo Diagnostic Right
MRA Head w/o Contrast
US Kidney Transplant Right
PET/CT Chest w/ Contrast
CT Maxillofacial w/o Contrast
XR Elbow Complete Right
IR FL Guide BX/ASP/INJ
MRI MRCP w/o Contrast
XR Elbow Complete Left
MRI Pelvis w/ + w/o Contrast
PET/CT Abdomen and Pelvis w/ Contrast
NM Myocardial Perf Multi Spect
MRI Spine Cervical w/ + w/o Contrast
XR Foot Complete Bilat
XR Upper GI w/ Video Esophagram
XR Swallowing Function w/ Video
MRI Knee w/o Contrast Left
XR Femur Right
NM Bone Imaging Whole Body
XR Tibia/Fibula Right
MRI Knee w/o Contrast Right
MRI Breast w/ + w/o Contrast Bilateral
CT Sinuses w/o Contrast
CT Outside Image Review-Body
XR Tibia/Fibula Left
CTA Abd/Pelvis 4 Phase Liver Protocol
11
Other Specialty:* This field is required.
12
AttachmentsPlease upload any attachments to this secure form (e.g. labs, scans, demographic sheet, etc.)
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Max. file size: 10.6MB
This is a HIPAA compliant form.
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