Thank you for your interest in the UAB Environmental Lung Disease Clinic. Your completion of all the fields below and attachment of medical records will ensure that there are no unnecessary delays in the evaluation of your patient.
Reason for Referral
(Required)
Please select the option that best describes you.
I am a referring provider
I am a patient or guardian
Third party referrer (DOL, legal, workman’s comp, other)
Request Priority
Urgent (1-2 weeks)
4 weeks
6 weeks-3 months
First available
Patient Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
If you are a 3rd Party Referrer, Include Case #
Patient Phone Number
(Required)
Alternate Phone Number
(Required)
Referring MD/Third Party
(Required)
First
Last
NPI
Referring MD/Third Party Office Number
(Required)
Referring MD/Third Party Fax Number
(Required)
Additional Remarks
Please upload or fax our office with relevant pulmonary (lung) diagnosis records only.
Copy of front/back of insurance cards (if available)
Most recent clinic notes
Most recent pulmonary testing reports (pulmonary function testing, ABGs, CPET, walk test)
For testing with associated images (Chest Xray, CT, PET) please send a copy of the most recent testing via PACS or call us at 205-934-7557 for an Ambra link.
If using PACS, please indicate in the Additional Remarks box above: PACS images
Please note, we will contact the patient to notify them of appointment details.
Drop files here or
Select files
Max. file size: 8 MB.
You may upload patient's records and insurance cards to help ease the appointment process.