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
Specialty Requested
Specific Physician Requested (Optional)
10
Attachments* This field is required.Please 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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