Thank you for your interest in the UAB Medicine.

For your convenience, we offer two easy methods to refer your patient. Click here to download a printable form, which may be completed and faxed back to us, or simply complete and submit the electronic form below and we will contact your office.
Patient Name(Required)
Address(Required)
MM slash DD slash YYYY
Physician(Required)
MM slash DD slash YYYY
Office Contact Person(Required)

Please make sure that all order requirements are met before sending order or scheduling patients.

ORDER FORM REQUIREMENTS

  • Attach your most recent clinic notes, to help us better serve your patient.
  • Make certain that TKC EKG prep instructions are given to the patient.
  • Schedule the patient via Medicine Scheduling by calling 205-801-5655.
Max. file size: 8 MB.
Test Type(Required)
Monitor(Required)
Duration(Required)
Duration
Duration(Required)
Diagnosis(Required)
NOTICE: For the clinic to bill properly and receive payment for tests you have ordered, it is critical that the diagnosis you provide is consistent with the information recorded in the patient’s medical record. The Department of Health and Human Services requires that all tests ordered for Medicare beneficiaries be reasonable and necessary. If the diagnosis you provide does not support the medical necessity of the test ordered under Medicare program standards, Medicare will deny payment, and the beneficiary may be financially responsible for the test.
Services to be charged to