Cardiac Surgery »  Patient Center »  RAA Form
Refer a Patient

This online form is for physicians and other health professionals to refer a patient to UCSF Cardiac Surgery. If you are NOT a physician or health professional, please use our Request an Appointment Form.

Please complete the form below to initiate a referral request. Appointments by phone may also be made by calling (415) 353-1606. This is a secure form and any information provided will be handled in strict compliance with applicable privacy laws.

* indicates required field

Patient Information

 
* First Name:
  
* Last Name:
 
* Address:
  
Apartment/Suite No:
* City:
  
* State:
  
* Zip / Postal Code:
  
* Country:
 
* Daytime Phone No:
 
Alternate Phone No:

Email Address:
* Date of Birth:

Example: 02/20/1980
 
* Gender:
 
How did you hear about UCSF?

Referring Provider Information

* First Name:
  
* Last Name:
 
* Address:
  
Office Suite No:
* City:
  
* State:
  
* Zip / Postal Code:
  
* Country:
  
* Office Phone No:
   
Office Fax No:
Cell Phone No:
Pager:
Email Address:

Primary Care Physician Information

* Are you the Primary Care Physician?

If no, please provide the following information (if known).

Name of Primary Care Physician:
Primary Care Physician's Phone:

Insurance Information

Select the patient's medical plan from the dropdown list. If not listed, type the plan into the box “Other”.
* Medical Plan:    
Other:
Group No:
Subscriber No:
Does the patient have secondary or supplemental health insurance?
*Secondary Medical Plan:    
Other:
Group No:
Subscriber No:
* Does the patient have a physician referral?
 

Reason For Appointment

* Please indicate the nature of the patient's medical issue or problem below.   

Desired Physician or Provider

If the patient has a physician or provider preference, please make your selection here.

Desired Physician or Provider:
Has the patient seen this provider before?

Diagnostic Tests

Please check all tests performed to diagnose the patient's condition.




Other:

Additional Information

Please provide any other relevant information about the patient's treatment in the space below.

Please review the information you provided above. Then click the Submit button. A Cardiac Surgery Program Specialist should be contacting you within one business day. Should you have any additional questions or concerns, please contact the clinic directly at (415) 353-1606.

*  Please type the verification characters below into the yellow box and press "Submit". You will then receive a confirmation message on the screen. Please do not press “Submit” more than once.

 


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