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Physician Referral Form
Physician Referral Form
Please fill out and submit this HIPAA compliant and secured form to refer a patient to a Keck Medicine of USC physician. 
10Questions
Physician Referral Form - Keck Medicine of USC
  • 1
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  • 2
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  • 3
    Tell us about yourself.
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  • 4
    How may we reach you?
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  • 5
    To help expedite the referral, provide the patients details below
    • Yes
    • No
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  • 6
    This is required for patients with HMO Insurance
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    Max. file size: 10.6MB
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  • 7
    Tell us about the patient you are referring. 
    • Male
    • Female
    • Non-binary
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  • 8
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  • 9
    If this patient is a minor, please provide the following details:
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  • 10
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  • 11
    • 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
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  • 12
    Please select all that apply.
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  • 13
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  • 14
    Please upload any attachments to this secure form (e.g. labs, scans, demographic sheet, etc.) 
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    Max. file size: 10.6MB
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  • Should be Empty:
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