eMedicine Referral Form

Date(Required)

Referring MD(Required)

First Last

City/State(Required)

Phone Number(Required)

Fax(Required)

Office Contact(Required)

First Last

Patient Information

Full Name(Required)

First Last

Date of Birth(Required)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insurance(Required)

Contract #(Required)

Group #(Required)

Effective Date(Required)

Name on Insurance(Required)

First Last

Date of Birth(Required)

Secondary Insurance

Contract #

Group #

Effective Date

Name on Insurance

Date of Birth

Diagnosis/Reason for Referral(Required)

Specialty Requested(Required)

UAB MD Requested(Required)

First Last

Notes

Thank you for choosing UAB Medicine.

You will be contacted for additional information as needed.