Priority Access Referral Form

Thank you for choosing UAB Medicine. We welcome the opportunity to partner with you in caring for your patients. If you have any questions or prefer to speak to a UAB Medicine Priority Access specialist, please call 205-801-8686.

Date(Required)

Referring MD(Required)

First Last

City/State

Phone Number

Fax

Office Contact

First Last

Patient Information

Full Name

First Last

Date of Birth(Required)

Phone Number

Address

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

Primary Insurance(Required)

Contract #

Group #

Effective Date

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

UAB MD Requested

First Last

Notes

Thank you for choosing UAB Medicine.

A SCHEDULER WILL CONTACT YOU WITH THE APPOINTMENT INFORMATION.