UHC REFERRAL FORM

UHC Referral Form

To submit this referral online fill in the blanks below then click the SUBMIT button at the bottom of the page.

UHC AUTHORIZATION FORM

Check here if URGENT

YES, URGENT

Updated Request

2nd Request

Reason for urgent referral

Date of Appointment

(required if URGENT)

Referring MD

MD First Name

MD Last Name

MD ID Number

MD Type

PCP

Covering MD

Other

Contact Person

Contact Name

Contact Phone

Contact Fax

Your Email

Member Info

Member First Name

Member Last Name

Member Date of Birth

Member ID#

Member Group Number

Referred To:

Specialty MD First Name

Specialty MD Last Name

Specialty MD Address

Apt, suite, etc.

Country

City

State

Zip code

Referred to Fax

Specialist ID Number