Neurosurgery Referral Form

Our physicians see patients at The Kirklin Clinic of UAB Hospital, 2000 6th Avenue South – 2nd Floor Birmingham, AL , Medical West,5000 Medical W Wy, Bessemer, AL 35022 (Dr. Renee Chambers ONLY), and UAB Greystone, 7500 Hugh Daniel Dr., Suite 200, Birmingham, AL 35242

All new patient referral packets require a copy of the patient’s insurance card and photo ID.

UAB Neurosurgeon Requested

Prior to selecting a surgeon below, please review the PDF linked above.

DIAGNOSIS/Reason for referral (NOT CODES)(Required)

Patient's Full Name(Required)

First Middle Last

Gender

Date of Birth(Required)

Social Security Number

Mailing Address(Required)

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

Telephone Phone Number(Required)

Work Phone Number

Cell Phone Number

Email Address

Insurance Information

Insurance 1st

Group #

Contract #

Insurance 2nd

Group #

Contract #

Referring Physician(Required)

First Last Suffix

NPI

Please enter a number greater than or equal to 10.

Mailing Address

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

Telephone Number(Required)

Fax Number(Required)

Office Contact

First Last

Is this a Workers' Compensation injury?(Required)

Yes

Workers' Compensation Providing Company Information (if applicable)

Contact Name

First Last

Telephone Number

Address

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

Case/Approval Number(Required)

Date of Injury(Required)

Hidden

Section Break

Please fax all records to 205-934-6507.

Records(Required)

Checking this box confirms records and clinic notes have been faxed to (205) 934-6507. Please submit recent imaging via PACS, Ambra or mail to: UAB Neurosurgery, Neuroscience One, 2000 6th Ave. South, Birmingham, AL, 35233.