Physician Referral Intake Form | Physician Referrals| UC Davis Health

<!doctype html> <html lang="en"> <head> <meta charset="utf-8"> <meta http-equiv="X-UA-Compatible" content="IE=edge"> <meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no"> <title>Physician Referral Intake Form | Physician Referrals| UC Davis Health</title> <meta name="description" content="UC Davis Health electrocnic referral form for physicians "> <meta name="keywords" content="physician, referral, outpatient, UC Davis, University of California, Davis, healthcare, health care, Sacramento"> <meta name="copyright" content="Copyright UC Regents. For more information regarding the University of California's copyright terms, visit http://www.ucop.edu/services/terms.html">  <link rel="stylesheet" type="text/css" href="https://health.ucdavis.edu/assets/css/global.min.css?v=43"> <link rel="stylesheet" type="text/css" href="https://health.ucdavis.edu/assets/css/custom-css/custom.css"> <script src="GlobalJS/jquery-3.6.1.min.js"></script> <script src="GlobalJS/moment.min.js"></script> <script src="GlobalJS/bootstrap.bundle.min.js"></script> <script src="GlobalJS/bootstrap.min.js"></script> <script src="GlobalJS/bootstrap-datetimepicker.min.js"></script> <script src="GlobalJS/bootstrap-select.min.js"></script> <style> .select-input select.form-control { appearance: auto!important; display: block!important; padding-right: 1rem!important; } </style> </head> <script> //This function disables the submit button if the acknowledgement has not been selected function validateAck(ackBtn){ if (ackBtn.checked == 1){ document.getElementById('btnSubmitIntake').disabled = 0; document.getElementById('btnPrintIntake').disabled = 0; } if (ackBtn.checked == 0){ document.getElementById('btnSubmitIntake').disabled = 1; document.getElementById('btnPrintIntake').disabled = 1; } } function makePriorAuthReq(){ if (document.getElementById('prior_authorization1').checked){ document.getElementById('authorization').required = true; document.getElementById('visitNum').required = true; document.getElementById('insExp').required = true; } else { document.getElementById('authorization').required = false; document.getElementById('visitNum').required = false; document.getElementById('insExp').required = false;} } function makeSecInsReq(){ //alert('1'+document.getElementById('secondary1').checked); //alert('2'+document.getElementById('isecondary2').checked); if (document.getElementById('secondary1').checked){ document.getElementById('SUB_LNAME2').required = true; document.getElementById('SUB_FNAME2').required = true; document.getElementById('s2dob').required = true; document.getElementById('plan2').required = true; document.getElementById('member2').required = true;} else { document.getElementById('SUB_LNAME2').required = false; document.getElementById('SUB_FNAME2').required = false; document.getElementById('s2dob').required = false; document.getElementById('plan2').required = false; document.getElementById('member2').required = false;} } //this function sets the ICD value for self referrals function setICDSelf(myBool){ if (myBool){ document.getElementById('icd').value = 'R68.89'; document.getElementById('urgentRequest').style.display = 'none'; } else{ document.getElementById('icd').value = ''; document.getElementById('urgentRequest').style.display = ''; } } //this makes an AJAX call to getAddressAJAX.cfm, which calls UCD PITS to pull address based on NPI or License Number function getAddress(value, type){ var xhr = new XMLHttpRequest(); xhr.open('POST', 'getAddressAJAX.cfm', true); xhr.setRequestHeader("Content-type", "application/x-www-form-urlencoded"); xhr.send('value='+value+'&type='+type); xhr.onreadystatechange = function () { var DONE = 4; // readyState 4 means the request is done. var OK = 200; // status 200 is a successful return. if (xhr.readyState === DONE) { var myArray; if (xhr.status === OK) { if (this.responseText.length > 4){ myArray = (this.responseText).split("|"); document.getElementById('RF_OFF_ADDR').value = myArray[0]; document.getElementById('RF_OFF_CITY').value = myArray[1]; document.getElementById('RF_OFF_STATE').value = myArray[2]; document.getElementById('RF_OFF_ZIP').value = myArray[3]; } } else { } } }; } </script> <body> <div class="container-fluid TEMP-remove-this-div-in-dev">  <header class="brand-header mx-n4 mx-md-n5"> <div class="navskip"><a href="#content" class="sr-only sr-only-focusable" title="Skip to main content">Skip to main content</a></div> <div class="inner-header-container">  <div class="brands-container px-4 px-md-5 py-2 py-md-3"> <div class="wrapper d-flex align-items-center">  <div class="wordmark-container"> <a id="brand" class="wordmark" href="https://health.ucdavis.edu/welcome/" title="UC Davis Health">  <div class="d-inline-flex wordmark-primary-brand align-items-center py-2 py-md-1 mr-3"><img src="https://health.ucdavis.edu/assets/images/wordmarks/UCDavisHealth.svg" alt="UC Davis Health wordmark"></div>      </a></div>      <div class="search ml-auto"> <button id="desktop-search" class="btn btn-search d-none d-lg-block" data-target="#search" aria-controls="search" aria-expanded="false" aria-label="Opens search field overlay"> <svg viewBox="0 0 16 16" class="bi bi-search" fill="currentColor" xmlns="http://www.w3.org/2000/svg" role="presentation" alt="" focusable="false" aria-hidden="true"> <title>search icon</title> <path fill-rule="evenodd" d="M10.442 10.442a1 1 0 0 1 1.415 0l3.85 3.85a1 1 0 0 1-1.414 1.415l-3.85-3.85a1 1 0 0 1 0-1.415z"/> <path fill-rule="evenodd" d="M6.5 12a5.5 5.5 0 1 0 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goes here, e.g., Choose UC Davis Health</h1>  </div>   <div class="basic-header" id="content"> <div class="wrapper d-flex justify-content-center"> <div class="sizer col-lg-10"> <div class="basic-header-container row justify-content-center mx-0"> <div class="basic-header-body sizer col-lg-10"> <div class="section-header left-aligned bold mb-3 mb-sm-5"> <h2 class="section-title underlined mb-2 pb-3">Electronic Referral Intake Form</h2> </div> </div> </div> </div> </div> </div>  <div class="referral-form"> <div class="basic-content wrapper d-flex justify-content-center"> <div class="sizer col-lg-10"> <div class="basic-content-container article-container mx-0"> <div class="basic-content-body article-body form-container mb-6"> <div class="row alert alert-form info-prompt px-4 pt-4 pb-3 mb-4 mx-auto" role="alert"> <strong class="mb-2">Is your referral for any of the following departments? <span class="danger">*</span></strong> <div class="col-12 px-0 mb-3"> <ul class="mb-0 pl-5"> <li style="font-size: 1rem;">Comprehensive Cancer Center</li> <li style="font-size: 1rem;">Physical, Occupational and Speech Therapies – Non ENT related</li> <li style="font-size: 1rem;">Psychiatry - Adult</li> <li style="font-size: 1rem;">Radiology - Adult & Pediatric</li> <li style="font-size: 1rem;">Burn Surgery - Adult (Pediatric goes to Shriners)</li> <li style="font-size: 1rem;">Organ Transplants</li> </ul> </div> <span class="radio-inputs pr-5 mb-2"> <div class="form-check form-check-inline"> <input class="form-check-input disable_form" type="radio" required name="referral-department" id="referral-department1" value="Yes" aria-label="This is a referral for one of these departments"> <label class="form-check-label" for="referral-department1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input disable_form" type="radio" required name="referral-department" id="referral-department2" value="No" aria-label="This is not a referral for one of these departments"> <label class="form-check-label" for="referral-department2"> No </label> </div> </span> </div> <div class="referral-department disabled-message on-yes alert alert-form info-prompt p-4 mb-4 mx-auto hide" role="alert"> <p class="mb-3" style="font-size: 1rem;"><svg xmlns="http://www.w3.org/2000/svg" width="16" height="16" fill="currentColor" class="bi bi-info-circle mr-2" viewBox="0 0 16 16"><path d="M8 15A7 7 0 1 1 8 1a7 7 0 0 1 0 14zm0 1A8 8 0 1 0 8 0a8 8 0 0 0 0 16z"></path><path d="m8.93 6.588-2.29.287-.082.38.45.083c.294.07.352.176.288.469l-.738 3.468c-.194.897.105 1.319.808 1.319.545 0 1.178-.252 1.465-.598l.088-.416c-.2.176-.492.246-.686.246-.275 0-.375-.193-.304-.533L8.93 6.588zM9 4.5a1 1 0 1 1-2 0 1 1 0 0 1 2 0z"></path></svg><strong>Please do not submit this form. See the corresponding department's information below to submit a referral.</strong></p> <div class="ml-4"> <p class="mb-0" style="font-size: 1rem;"><strong>Comprehensive Cancer Center</strong></p> <p class="mb-3" style="font-size: 1rem;">Please call <a href="tel:916-734-5959">916-734-5959</a> for more information or <a href="https://health.ucdavis.edu/cancer/referring-clinicians/pdf/New-Patient-Referral-Form-UC-Davis-Comprehensive-Cancer-Center.pdf" title="go to form">complete this form</a> and fax it to <a href="tel:916-703-5266">916-703-5266</a>.</p> <p class="mb-0" style="font-size: 1rem;"><strong>Physical, Occupational and Speech Therapies – Non ENT related</strong></p> <p class="mb-3" style="font-size: 1rem;">Please call <a href="tel:916-734-6700">916-734-6700</a> for more information or fax referral to <a href="tel:916-646-5945">916-646-5945</a>.</p> <p class="mb-0" style="font-size: 1rem;"><strong>Psychiatry - Adult</strong></p> <p class="mb-3" style="font-size: 1rem;">Please call <a href="tel:916-734-3574">916-734-3574</a> for more information or fax referral to <a href="tel:916-734-0849">916-734-0849</a>.</p> <p class="mb-0" style="font-size: 1rem;"><strong>Radiology - Adult and Pediatric</strong></p> <p class="mb-3" style="font-size: 1rem;">Please call <a href="tel:916-734-0655">916-734-0655</a> for more information or fax referral/authorized order to <a href="tel:916-703-2254">916-703-2254</a>.</p> <p class="mb-0" style="font-size: 1rem;"><strong>Burn Surgery - Adult (Pediatric goes to Shriners)</strong></p> <p class="mb-3" style="font-size: 1rem;">Please call <a href="tel:916-703-6623">916-703-6623</a> for more information or fax referral/authorized order to <a href="tel:916-703-6229">916-703-6229</a>.</p> <p class="mb-0" style="font-size: 1rem;"><strong>Transplant Center</strong></p> <p class="mb-0" style="font-size: 1rem;">Please call <a href="tel:916-734-2111">916-734-2111</a> or <a href="https://health.ucdavis.edu/transplant/" title="go to website" target="_blank">visit the Transplant Center website</a>.</p>  </div> </div> <form class="referral-form needs-validation disabled" action="" id="referral-form" method="post" enctype="multipart/form-data"> <input type="hidden" name="physRefFormToken" value="F96472E41B165C093ED4A143289916263797EAC2" /> <input type="hidden" name="RF_status_id" value="1"> <input type="hidden" name="RF_contact_email" value=""> <input type="hidden" name="RF_completed_by" value="notLoggedInUser" /> <input type="hidden" name="RF_completed_by_DTS" value="{ts '2024-11-26 22:13:45'}" /> <input type="hidden" name="RF_created_DTS" value="{ts '2024-11-26 22:13:45'}" /> <div class="row d-flex alert alert-form info-prompt align-items-center px-4 pt-4 pb-3 mb-4"> <strong class="pr-5 mb-2">Is this a self-referral? <span class="danger">*</span></strong> <span class="radio-inputs pr-5 mb-2"> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" onChange="setICDSelf(true);" required name="self-referral" id="self-referral1" value="1" aria-label="This is a self-referral" > <label class="form-check-label" for="self-referral1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" onChange="setICDSelf(false);" required name="self-referral" id="self-referral2" value="0" checked="" aria-label="This is not a self-referral" > <label class="form-check-label" for="self-referral2"> No </label> </div> </span> <span class="self-referral hide d-flex flex-wrap align-items-center justify-content-start justify-content-md-end flex-fill mb-2"> <label for="RF_DATENEW2" class="pr-3 mb-0"><strong>Referral date</strong></label> <div class="input-group w-auto"> <input id="RF_DATENEW2" name="RF_DATENEW2" value="11/26/2024" readonly aria-label="Referral date"> </div> </span> </div> <div class="self-referral"> <div class="row d-flex alert alert-form info-prompt px-4 pt-4 pb-3 align-items-center mb-4"> <strong class="pr-5 mb-2">Are you the patient's PCP? <span class="danger">*</span></strong> <span class="radio-inputs pr-5 mb-2"> <div class="form-check form-check-inline"> <input class="form-check-input" type="radio" required name="pcp" id="pcp1" value="1" aria-label="I am the PCP"> <label class="form-check-label" for="pcp1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input" type="radio" required name="pcp" id="pcp2" value="0" checked="" aria-label="I am not the PCP"> <label class="form-check-label" for="pcp2"> No </label> </div> </span> <span class="d-flex flex-wrap align-items-center justify-content-start justify-content-md-end flex-fill mb-2"> <label for="RF_DATENEW" class="pr-3 mb-0"><strong>Referral date</strong></label> <div class="input-group w-auto"> <input id="RF_DATENEW" name="RF_DATENEW" value="11/26/2024" readonly aria-label="Referral date"> </div> </span> </div> </div> <div id="urgentRequest" class="alert-form row info-prompt alert px-4 pt-4 pb-3 mb-4 mx-auto" role="alert"> <strong class="pr-5 mb-2">Is this an urgent request? <span class="danger">*</span></strong> <span class="radio-inputs mb-2"> <div class="form-check form-check-inline"> <input class="form-check-input" required checked="" type="radio" name="urgent" id="urgent1" value="1" aria-label="Urgent"> <label class="form-check-label" for="urgent1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input" required checked="checked"type="radio" name="urgent" id="urgent2" value="0" aria-label="Not urgent"> <label class="form-check-label" for="urgent2"> No </label> </div> </span> </div> <h4 class="row d-flex px-0 pb-2 pt-4 mb-3 mx-auto"> Consultation request information </h4> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-4 required"> <label for="requested_specialty">Requested specialty</label> <input id="requested_specialty" class="form-control" aria-label="Requested specialist" type="text" name="RF_REQ_SPECIALTY" required value=""> </div> <div class="form-group col-sm-4"> <label for="specialist">Requested specialist</label> <input id="specialist" class="form-control" aria-label="Requested specialist" type="text" name="RF_REQ_PROVIDER_NAME" placeholder="If unknown, leave blank" value="" > </div> <div class="form-group col-sm-4"> <label for="service">Service requested</label> <div class="select-input"> <select name="RF_REQ_SERVICE" id="service" class="form-control" aria-label="Select service requested"> <option value="" selected="">Select...</option> <option value="1" >Consultation </option> <option value="2" >Second Opinion</option> <option value="3" >Surgery</option> <option value="4" >Other:</option> </select> </div> </div> </div> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-4 required"> <label for="icd">ICD-10 code(s):</label> <input id="icd" class="form-control" required aria-label="ICD-10 code(s)" type="text" name="RF_REQ_ICD10_1" value="" > </div> <div class="form-group col-sm-4"> <label for="icd2">ICD-10 code(s):</label> <input id="icd2" class="form-control" aria-label="ICD-10 code(s)" type="text" name="RF_REQ_ICD10_2" value="" > </div> <div class="form-group col-sm-4"> <label for="icd3">ICD-10 code(s):</label> <input id="icd3" class="form-control" aria-label="ICD-10 code(s):" type="text" name="RF_REQ_ICD10_3" value="" > </div> </div> <div class="row d-flex no-gutters justify-content-between"> <div class="form-group col-sm required"> <label for="reason">Reason for referral</label> <textarea id="reason" class="form-control" required aria-label="Reason for referral" name="RF_REQ_REASON"></textarea> </div> </div> <div class="self-referral"> <h4 class="row d-flex px-0 pb-2 pt-4 mb-3 mx-auto"> Referring provider information </h4> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-4 required"> <label for="RF_PROV_LNAME">Last name</label> <input id="RF_PROV_LNAME" class="form-control" required aria-label="Provider last name" type="text" name="RF_PROV_LNAME" placeholder="Last name" value=""> </div> <div class="form-group col-sm-3 required"> <label for="RF_PROV_FNAME">First name</label> <input id="RF_PROV_FNAME" class="form-control" required aria-label="provider first name" type="text" name="RF_PROV_FNAME" placeholder="First name" value=""> </div> <div class="form-group col-sm-2"> <label for="Select">Degree</label> <div class="select-input"> <select name="RF_PROV_DEGREE" id="RF_PROV_DEGREE" class="form-control" aria-label="Referring provider degree"> <option value="" selected="">---</option> <option value="5" >D.O.</option> <option value="1" >M.D.</option> <option value="3" >N.P.</option> <option value="6" >O.D.</option> <option value="4" >P.A.</option> <option value="2" >Ph.D.</option> </select> </div> </div> <div class="form-group col-sm-3"> <label for="RF_PROV_EMAIL">Business/practice email address</label> <input id="RF_PROV_EMAIL" maxlength="200" class="form-control" value="" aria-label="Referring provider business/practice email address" type="email" name="RF_PROV_EMAIL" value=""> </div> </div> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-4 required"> <label for="RF_PROV_LICENSE">License number</label> <input onChange="getAddress(this.value,'license')" id="RF_PROV_LICENSE" required class="form-control" aria-label="Referring provider licence number" type="text" name="RF_PROV_LICENSE" value=""> </div> <div class="form-group col-sm-4 required"> <label for="RF_PROV_NPI">NPI number</label> <input onChange="getAddress(this.value,'npi')" id="RF_PROV_NPI" class="form-control" aria-label="Referring provider NPI number" type="text" name="RF_PROV_NPI" required value=""> </div> <div class="form-group col-sm-4 required"> <label for="RF_PROV_SPECIALTY">Primary specialty</label> <input class="form-control" required id="RF_PROV_SPECIALTY" name="RF_PROV_SPECIALTY" aria-label="Referring provider primary specialty" type="text" value=""> </div> </div> <hr class="mx-auto mb-4"> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-3 required"> <label for="RF_facility_name">Office/facility name</label> <input id="RF_facility_name" required class="form-control" aria-label="Referring provider office or facility name" type="text" name="RF_facility_name" value=""> </div> <div class="form-group col-sm-3 required"> <label for="RF_contact_name">Office contact name</label> <input id="RF_contact_name" required class="form-control" aria-label="Referring provider office contact name" type="text" name="RF_contact_name" placeholder="First and last name" value=""> </div> <div class="form-group col-sm-3 required"> <label for="RF_contact_phone">Office contact phone</label> <input id="RF_contact_phone" required class="form-control" aria-label="Referring provider office contact phone" type="tel" name="RF_contact_phone" placeholder="(555)-555-5555" value=""> </div> <div class="form-group col-sm-3 required"> <label for="RF_OFF_FAX">Office fax</label> <input id="RF_OFF_FAX" required class="form-control" aria-label="Referring provider office fax" type="tel" name="RF_OFF_FAX" value=""> </div> </div> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-4 required"> <label for="RF_OFF_ADDR">Office address</label> <input id="RF_OFF_ADDR" required class="form-control" aria-label="Referring provider office address" type="text" name="RF_OFF_ADDR" placeholder="1234 Medicine Street" value=""> </div> <div class="form-group col-sm-4 required"> <label for="RF_OFF_CITY">City</label> <input id="RF_OFF_CITY" required class="form-control" aria-label="Referring provider office city" type="text" name="RF_OFF_CITY" value=""> </div> <div class="form-group col-sm-2 required"> <label for="RF_OFF_STATE">State</label> <div class="select-input"> <select name="RF_OFF_STATE" id="RF_OFF_STATE" class="form-control" aria-label="Referring provider office state"> <option value="" selected >Select</option> <option value="AL" >AL - ALABAMA</option> <option value="AK" >AK - ALASKA</option> <option value="AS" >AS - AMERICAN SAMOA</option> <option value="AZ" >AZ - ARIZONA</option> <option value="AR" >AR - ARKANSAS</option> <option value="CA" >CA - CALIFORNIA</option> <option value="CO" >CO - COLORADO</option> <option value="CT" >CT - CONNECTICUT</option> <option value="DE" >DE - DELAWARE</option> <option value="DC" >DC - DISTRICT OF COLUMBIA</option> <option value="FL" >FL - FLORIDA</option> <option value="GA" >GA - GEORGIA</option> <option value="GU" >GU - GUAM</option> <option value="HI" >HI - HAWAII</option> <option value="ID" >ID - IDAHO</option> <option value="IL" >IL - ILLINOIS</option> <option value="IN" >IN - INDIANA</option> <option value="IA" >IA - IOWA</option> <option value="KS" >KS - KANSAS</option> <option value="KY" >KY - KENTUCKY</option> <option value="LA" >LA - LOUISIANA</option> <option value="ME" >ME - MAINE</option> <option value="MD" >MD - MARYLAND</option> <option value="MA" >MA - MASSACHUSETTS</option> <option value="MI" >MI - MICHIGAN</option> <option value="MN" >MN - MINNESOTA</option> <option value="MS" >MS - MISSISSIPPI</option> <option value="MO" >MO - MISSOURI</option> <option value="MT" >MT - MONTANA</option> <option value="NE" >NE - NEBRASKA</option> <option value="NV" >NV - NEVADA</option> <option value="NH" >NH - NEW HAMPSHIRE</option> <option value="NJ" >NJ - NEW JERSEY</option> <option value="NM" >NM - NEW MEXICO</option> <option value="NY" >NY - NEW YORK</option> <option value="NC" >NC - NORTH CAROLINA</option> <option value="ND" >ND - NORTH DAKOTA</option> <option value="MP" >MP - NORTHERN MARIANA IS</option> <option value="OH" >OH - OHIO</option> <option value="OK" >OK - OKLAHOMA</option> <option value="OR" >OR - OREGON</option> <option value="PA" >PA - PENNSYLVANIA</option> <option value="PR" >PR - PUERTO RICO</option> <option value="RI" >RI - RHODE ISLAND</option> <option value="SC" >SC - SOUTH CAROLINA</option> <option value="SD" >SD - SOUTH DAKOTA</option> <option value="TN" >TN - TENNESSEE</option> <option value="TX" >TX - TEXAS</option> <option value="UT" >UT - UTAH</option> <option value="VT" >VT - VERMONT</option> <option value="VA" >VA - VIRGINIA</option> <option value="VI" >VI - VIRGIN ISLANDS</option> <option value="WA" >WA - WASHINGTON</option> <option value="WV" >WV - WEST VIRGINIA</option> <option value="WI" >WI - WISCONSIN</option> <option value="WY" >WY - WYOMING</option> </select> </div> </div> <div class="form-group col-sm-2 required"> <label for="RF_OFF_ZIP">Zip</label> <input id="RF_OFF_ZIP" required class="form-control" aria-label="Referring provider office zip code" type="text" name="RF_OFF_ZIP" value=""> </div> </div> </div> <h4 class="row d-flex px-0 pb-2 pt-4 mb-3 mx-auto"> Patient information </h4> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-4 required"> <label for="RF_PAT_LNAME">Patient last name</label> <input id="RF_PAT_LNAME" required class="form-control" aria-label="patient last name" type="text" name="RF_PAT_LNAME" value=""> </div> <div class="form-group col-sm-4 required"> <label for="RF_PAT_FNAME">Patient first name</label> <input id="RF_PAT_FNAME" required class="form-control" aria-label="patient first name" type="text" name="RF_PAT_FNAME" value=""> </div> <div class="form-group col-sm-4 required"> <label for="RF_PAT_DOB">Date of birth</label> <input id="RF_PAT_DOB" class="form-control" required aria-label="patient date of birth" type="text" name="RF_PAT_DOB" placeholder="mm/dd/yyyy" value=""> </div> <div class="form-group col-sm-3"> <label for="RF_PAT_PARENT">If minor, name of parent</label> <input id="RF_PAT_PARENT" class="form-control" aria-label="If minor, name of patient's parent" type="text" name="RF_PAT_PARENT" placeholder="Caregiver / guardian" value=""> </div> <div class="form-group col-sm-3"> <label for="RF_PAT_PARENT_EMAIL">Patient/guardian email</label> <input id="RF_PAT_PARENT_EMAIL" maxlength="200" class="form-control" value="" aria-label="Patient or guardian email" type="email" name="RF_PAT_PARENT_EMAIL" value="" > </div> <div class="form-group col-sm-3 required"> <label for="RF_PAT_GENDER">Gender</label> <div class="select-input"> <select name="RF_PAT_GENDER" id="RF_PAT_GENDER" class="form-control" required="" aria-label="patient gender"> <option value="" selected >---</option> <option value="F" >Female</option> <option value="M" >Male</option> <option value="U" >Does not identify</option> </select> </div> </div> <div class="form-group col-sm-3"> <label for="RF_PAT_SSN">SSN</label> <input id="RF_PAT_SSN" class="form-control" aria-label="patient Social Security Number" type="text" name="RF_PAT_SSN" placeholder="333-22-4444" value=""> </div> <div class="form-group col-8 col-sm-4 col-lg-3 required"> <label for="RF_PAT_PHONE1">Phone number</label> <input value="" id="RF_PAT_PHONE1" required class="form-control" aria-label="patient contact phone (home or cell) number, first" type="tel" name="RF_PAT_PHONE1" placeholder="(555)-555-5555"> </div> <div class="form-group col-4 col-sm-2 col-lg-3 d-flex align-items-end"> <div class="row col-12 d-flex flex-column mx-0 px-0"> <div class="form-check form-check-inline"> <input class="form-check-input" type="radio" name="RF_PAT_PHONE1_TYPE" id="referring_patient_phone1_home" value="1" aria-label="This phone number is a home phone" checked=""> <label class="form-check-label" for="referring_patient_phone1_home"> Home </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input" type="radio" name="RF_PAT_PHONE1_TYPE" id="referring_patient_phone1_cell" value="0" aria-label="This phone number is a cell phone"> <label class="form-check-label" for="referring_patient_phone1_cell"> Cell </label> </div> </div> </div> <div class="form-group col-8 col-sm-4 col-lg-3"> <label for="RF_PAT_PHONE2">Phone number</label> <input value="" id="RF_PAT_PHONE2" class="form-control" aria-label="patient contact phone (home or cell) number, second" type="tel" name="RF_PAT_PHONE2" placeholder="(555)-555-5555"> </div> <div class="form-group col-4 col-sm-2 col-lg-3 d-flex align-items-end"> <div class="row col-12 d-flex flex-column mx-0 px-0"> <div class="form-check form-check-inline"> <input class="form-check-input" type="radio" name="RF_PAT_PHONE2_TYPE" id="referring_patient_phone2_home" value="1" aria-label="This phone number is a home phone"> <label class="form-check-label" for="referring_patient_phone2_home"> Home </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input" type="radio" name="RF_PAT_PHONE2_TYPE" id="referring_patient_phone2_cell" value="0" aria-label="This phone number is a cell phone" checked=""> <label class="form-check-label" for="referring_patient_phone2_cell"> Cell </label> </div> </div> </div> </div> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-3 required"> <label for="RF_PAT_ADDR">Address</label> <input id="RF_PAT_ADDR" required class="form-control" aria-label="patient address" type="text" name="RF_PAT_ADDR" placeholder="1234 Rivendale Rd" value=""> </div> <div class="form-group col-sm-3 required"> <label for="RF_PAT_CITY">City</label> <input id="RF_PAT_CITY" required class="form-control" aria-label="patient address city" type="text" name="RF_PAT_CITY" value=""> </div> <div class="form-group col-sm-3 required"> <label for="RF_PAT_STATE">State</label> <div class="select-input"> <select name="RF_PAT_STATE" id="RF_PAT_STATE" class="form-control" required="" aria-label="patient address state"> <option selected value="">Select</option> <option value="AL" >AL - ALABAMA</option> <option value="AK" >AK - ALASKA</option> <option value="AS" >AS - AMERICAN SAMOA</option> <option value="AZ" >AZ - ARIZONA</option> <option value="AR" >AR - ARKANSAS</option> <option value="CA" >CA - CALIFORNIA</option> <option value="CO" >CO - COLORADO</option> <option value="CT" >CT - CONNECTICUT</option> <option value="DE" >DE - DELAWARE</option> <option value="DC" >DC - DISTRICT OF COLUMBIA</option> <option value="FL" >FL - FLORIDA</option> <option value="GA" >GA - GEORGIA</option> <option value="GU" >GU - GUAM</option> <option value="HI" >HI - HAWAII</option> <option value="ID" >ID - IDAHO</option> <option value="IL" >IL - ILLINOIS</option> <option value="IN" >IN - INDIANA</option> <option value="IA" >IA - IOWA</option> <option value="KS" >KS - KANSAS</option> <option value="KY" >KY - KENTUCKY</option> <option value="LA" >LA - LOUISIANA</option> <option value="ME" >ME - MAINE</option> <option value="MD" >MD - MARYLAND</option> <option value="MA" >MA - MASSACHUSETTS</option> <option value="MI" >MI - MICHIGAN</option> <option value="MN" >MN - MINNESOTA</option> <option value="MS" >MS - MISSISSIPPI</option> <option value="MO" >MO - MISSOURI</option> <option value="MT" >MT - MONTANA</option> <option value="NE" >NE - NEBRASKA</option> <option value="NV" >NV - NEVADA</option> <option value="NH" >NH - NEW HAMPSHIRE</option> <option value="NJ" >NJ - NEW JERSEY</option> <option value="NM" >NM - NEW MEXICO</option> <option value="NY" >NY - NEW YORK</option> <option value="NC" >NC - NORTH CAROLINA</option> <option value="ND" >ND - NORTH DAKOTA</option> <option value="MP" >MP - NORTHERN MARIANA IS</option> <option value="OH" >OH - OHIO</option> <option value="OK" >OK - OKLAHOMA</option> <option value="OR" >OR - OREGON</option> <option value="PA" >PA - PENNSYLVANIA</option> <option value="PR" >PR - PUERTO RICO</option> <option value="RI" >RI - RHODE ISLAND</option> <option value="SC" >SC - SOUTH CAROLINA</option> <option value="SD" >SD - SOUTH DAKOTA</option> <option value="TN" >TN - TENNESSEE</option> <option value="TX" >TX - TEXAS</option> <option value="UT" >UT - UTAH</option> <option value="VT" >VT - VERMONT</option> <option value="VA" >VA - VIRGINIA</option> <option value="VI" >VI - VIRGIN ISLANDS</option> <option value="WA" >WA - WASHINGTON</option> <option value="WV" >WV - WEST VIRGINIA</option> <option value="WI" >WI - WISCONSIN</option> <option value="WY" >WY - WYOMING</option> </select> </div> </div> <div class="form-group col-sm-3 required"> <label for="RF_PAT_ZIP">Zip</label> <input id="RF_PAT_ZIP" required class="form-control" aria-label="patient address zip code" type="text" name="RF_PAT_ZIP" value=""> </div> </div> <div class="row d-flex align-items-center mx-0 px-0 pt-2 pb-2"> <strong class="pr-5 pb-2">Interpreter needed?</strong> <span class="pr-5 pb-2"> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" name="RF_PAT_INTERPRETER" id="interpreter1" value="1" aria-label="Interpreter needed" > <label class="form-check-label" for="interpreter1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" name="RF_PAT_INTERPRETER" id="interpreter2" value="0" aria-label="Interpreter not needed" checked="" checked > <label class="form-check-label" for="interpreter2"> No </label> </div> </span> <span class="d-flex align-items-center pb-2"> <strong class="RF_PAT_INTERPRETER hide">Language</strong> <div class="form-group RF_PAT_INTERPRETER hide pl-3 mb-0"> <input id="RF_PAT_LANGUAGE" class="form-control" aria-label="interpreter language needed" type="text" name="RF_PAT_LANGUAGE" value=""> </div> </span> </div> <h4 class="row d-flex px-0 pb-2 pt-4 mb-0 mx-auto"> Worker's Compensation </h4> <div class="row d-flex alert alert-form px-4 pt-4 pb-3 align-items-center info-prompt mb-3 mx-auto"> <strong class="pr-5 mb-2">Is this insurance claim work related? <span class="danger">*</span></strong> <span class="mb-2"> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" name="worker_comp" id="worker_comp1" value="1" aria-label="Work related" > <label class="form-check-label" for="worker_comp1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" name="worker_comp" id="worker_comp2" value="0" aria-label="Not work related" checked="" checked > <label class="form-check-label" for="worker_comp2"> No </label> </div> </span> </div> <span class="worker_comp"> <h4 class="row d-flex px-0 pb-2 pt-4 mb-3 mx-auto"> Insurance/authorization information </h4> <div class="mb-2 insurance hide px-0"> <div class="custom-file no-bottom-radius"> <input type="file" class="file-input" id="card_copy" name="RF_attch_InsCard_hidden" accept=".pdf, .jpg, .jpeg" aria-label="Upload copy of insurance card if available"> <label class="custom-file-label" for="card_copy">Copy of insurance card if available</label> </div> <div class="file_list card_copy p-3 hide"><span class="close" aria-label="remove uploaded files" data-value="card_copy"></span></div> <div class="custom-file no-top-radius"> <input type="file" multiple class="file-input" id="card2" name="RF_attch_InsCard2" accept=".pdf, .jpg, .jpeg" aria-label="Upload copy of secondary insurance card (if applicable)"> <label class="custom-file-label" for="card2">Copy of secondary insurance card (if applicable)</label> </div> <div class="file_list card2 p-3 hide"><span class="close" aria-label="remove uploaded files" data-value="card2"></span></div> </div> <div class="row d-flex insurance justify-content-between"> <div class="form-group col-sm-5 required"> <label for="SUB_LNAME">Subscriber last name</label> <input id="SUB_LNAME" class="form-control" required aria-label="Subscriber last Name" type="text" name="RF_INS_SUB_LNAME" value=""> </div> <div class="form-group col-sm-4 required"> <label for="SUB_FNAME">Subscriber first name</label> <input id="SUB_FNAME" class="form-control" required aria-label="Subscriber first Name" type="text" name="RF_INS_SUB_FNAME" value=""> </div> <div class="form-group col-sm-3 required"> <label for="sdob">Date of birth</label> <input id="sdob" class="form-control" required aria-label="Subscriber date of birth" type="text" name="RF_INS_SUBDOB1" placeholder="mm/dd/yyyy" value=""> </div> </div> <div class="row d-flex insurance justify-content-between"> <div class="form-group col-sm-5 required"> <label for="plan">Insurance/plan name</label> <input id="plan" class="form-control" required aria-label="Insurance/plan name" type="text" name="RF_INS_NAME1" placeholder="Cigna, Anthem, etc." value=""> </div> <div class="form-group col-sm-4 required"> <label for="member">Member ID</label> <input id="member" class="form-control" required aria-label="Member ID" type="text" name="RF_INS_MEMNUM1" value=""> </div> <div class="form-group col-sm-3"> <label for="group">Group number</label> <input id="group" class="form-control" aria-label="Group number" type="text" name="RF_INS_GROUP1" value=""> </div> </div> <div class="row d-flex insurance mx-0 pt-2 pb-3"> <strong class="pr-5 pb-2">Is prior authorization required?</strong> <span class="radio-inputs"> <div class="form-check form-check-inline"> <input class="form-check-input" onChange="makePriorAuthReq();" type="radio" name="rf_prior_authorization" id="prior_authorization1" value="1" aria-label="Yes, prior authorization is required"> <label class="form-check-label" for="prior_authorization1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input" onChange="makePriorAuthReq();" type="radio" name="rf_prior_authorization" id="prior_authorization2" value="0" aria-label="No, prior authorization isn't required" checked=""> <label class="form-check-label" for="prior_authorization2"> No </label> </div> </span> </div> <div class="row d-flex px-0 insurance"> <div class="form-group col-sm-5"> <label for="authorization">Prior authorization number</label> <input id="authorization" class="form-control" aria-label="Prior authorization number" type="text" name="RF_INS_AUTH1" value=""> </div> <div class="form-group col-sm-4"> <label for="visitNum">Number of visits authorized</label> <input id="visitNum" class="form-control" aria-label="Number of visits authorized" type="text" name="RF_INS_VISITNUM1" value=""> </div> <div class="form-group col-sm-3"> <label for="insExp">Expiration date</label> <input id="insExp" class="form-control datetimepicker_date-only" aria-label="Expiration date" type="text" name="RF_INS_EXPIRE1" placeholder="Select date" value=""> </div> </div> <div class="row d-flex pt-2 pb-2 px-0 insurance"> <div class="col-12"> <div class="row mx-0"> <strong class="pr-5 pb-2">Does the subscriber have a secondary insurance?</strong> <span class="radio-inputs"> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" onChange="makeSecInsReq();" name="secondary" id="secondary1" value="Yes" aria-label="Secondary insurance included" > <label class="form-check-label" for="secondary1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" onChange="makeSecInsReq();" name="secondary" id="isecondary2" value="No" aria-label="Secondary insurance not included" checked="" checked > <label class="form-check-label" for="secondary2"> No </label> </div> </span> </div> </div> <div class="col-12 secondary hide justify-content-between mt-3"> <div class="row"> <div class="form-group col-sm-5"> <label for="SUB_LNAME2">Subscriber last name</label> <input id="SUB_LNAME2" class="form-control" aria-label="Subscriber last Name" type="text" name="RF_INS_SUB_LNAME2" value=""> </div> <div class="form-group col-sm-4"> <label for="SUB_FNAME2">Subscriber first name</label> <input id="SUB_FNAME2" class="form-control" aria-label="Subscriber first Name" type="text" name="RF_INS_SUB_FNAME2" value=""> </div> <div class="form-group col-sm-3"> <label for="s2dob">Date of birth</label> <input id="s2dob" class="form-control" aria-label="Subscriber date of birth" type="text" name="RF_INS_SUBDOB2" placeholder="mm/dd/yyyy" value=""> </div> </div> </div> <div class="col-12 secondary hide justify-content-between"> <div class="row"> <div class="form-group col-sm-5"> <label for="plan2">Insurance/plan name</label> <input id="plan2" class="form-control" aria-label="Insurance/plan name" type="text" name="RF_INS_NAME2" placeholder="Cigna, Anthem, etc." value=""> </div> <div class="form-group col-sm-4"> <label for="member2">Member ID</label> <input id="member2" class="form-control" aria-label="Member ID" type="text" name="RF_INS_MEMNUM2" value=""> </div> <div class="form-group col-sm-3"> <label for="group2">Group number</label> <input id="group2" class="form-control" aria-label="Group number" type="text" name="RF_INS_GROUP2" value=""> </div> </div> </div> <div class="col-12 secondary hide"> <div class="row"> <div class="form-group col-sm-5"> <label for="authorization2">Prior authorization number</label> <input id="authorization2" class="form-control" aria-label="Prior authorization number" type="text" name="RF_INS_AUTH2" value=""> </div> <div class="form-group col-sm-4"> <label for="visitNum2">Number of visits authorized</label> <input id="visitNum2" class="form-control" aria-label="Number of visits authorized" type="text" name="RF_INS_VISITNUM2" placeholder="Select date" value=""> </div> <div class="form-group col-sm-3"> <label for="insExp2">Expiration date</label> <input id="insExp2" class="form-control datetimepicker_date-only" aria-label="Expiration date" type="text" name="RF_INS_EXPIRE2" value=""> </div> </div> </div> </div> </span> <div class="row d-flex worker_comp hide"> <div class="form-group col-sm"> <label for="carrier_name">Carrier name</label> <input id="carrier_name" class="form-control" aria-label="Carrier Name" type="text" name="RF_WC_NAME" value=""> </div> </div> <div class="row d-flex worker_comp hide justify-content-between"> <div class="form-group col-sm-6"> <label for="carrier_address">Address</label> <input id="carrier_address" class="form-control" aria-label="Address" type="text" name="RF_WC_ADDRESS" placeholder="Street address" value=""> </div> <div class="form-group col-sm-2"> <label for="carrier_city">City</label> <input id="carrier_city" class="form-control" aria-label="City" type="text" name="RF_WC_CITY" value=""> </div> <div class="form-group col-sm-2"> <label for="carrier_state">State</label> <div class="select-input"> <select name="RF_WC_STATE" id="carrier_state" class="form-control" aria-label="State"> <option selected value="">Select</option> <option value="AL" >AL - ALABAMA</option> <option value="AK" >AK - ALASKA</option> <option value="AS" >AS - AMERICAN SAMOA</option> <option value="AZ" >AZ - ARIZONA</option> <option value="AR" >AR - ARKANSAS</option> <option value="CA" >CA - CALIFORNIA</option> <option value="CO" >CO - COLORADO</option> <option value="CT" >CT - CONNECTICUT</option> <option value="DE" >DE - DELAWARE</option> <option value="DC" >DC - DISTRICT OF COLUMBIA</option> <option value="FL" >FL - FLORIDA</option> <option value="GA" >GA - GEORGIA</option> <option value="GU" >GU - GUAM</option> <option value="HI" >HI - HAWAII</option> <option value="ID" >ID - IDAHO</option> <option value="IL" >IL - ILLINOIS</option> <option value="IN" >IN - INDIANA</option> <option value="IA" >IA - IOWA</option> <option value="KS" >KS - KANSAS</option> <option value="KY" >KY - KENTUCKY</option> <option value="LA" >LA - LOUISIANA</option> <option value="ME" >ME - MAINE</option> <option value="MD" >MD - MARYLAND</option> <option value="MA" >MA - MASSACHUSETTS</option> <option value="MI" >MI - MICHIGAN</option> <option value="MN" >MN - MINNESOTA</option> <option value="MS" >MS - MISSISSIPPI</option> <option value="MO" >MO - MISSOURI</option> <option value="MT" >MT - MONTANA</option> <option value="NE" >NE - NEBRASKA</option> <option value="NV" >NV - NEVADA</option> <option value="NH" >NH - NEW HAMPSHIRE</option> <option value="NJ" >NJ - NEW JERSEY</option> <option value="NM" >NM - NEW MEXICO</option> <option value="NY" >NY - NEW YORK</option> <option value="NC" >NC - NORTH CAROLINA</option> <option value="ND" >ND - NORTH DAKOTA</option> <option value="MP" >MP - NORTHERN MARIANA IS</option> <option value="OH" >OH - OHIO</option> <option value="OK" >OK - OKLAHOMA</option> <option value="OR" >OR - OREGON</option> <option value="PA" >PA - PENNSYLVANIA</option> <option value="PR" >PR - PUERTO RICO</option> <option value="RI" >RI - RHODE ISLAND</option> <option value="SC" >SC - SOUTH CAROLINA</option> <option value="SD" >SD - SOUTH DAKOTA</option> <option value="TN" >TN - TENNESSEE</option> <option value="TX" >TX - TEXAS</option> <option value="UT" >UT - UTAH</option> <option value="VT" >VT - VERMONT</option> <option value="VA" >VA - VIRGINIA</option> <option value="VI" >VI - VIRGIN ISLANDS</option> <option value="WA" >WA - WASHINGTON</option> <option value="WV" >WV - WEST VIRGINIA</option> <option value="WI" >WI - WISCONSIN</option> <option value="WY" >WY - WYOMING</option> </select> </div> </div> <div class="form-group col-sm-2"> <label for="carrier_zip">Zip</label> <input id="carrier_zip" class="form-control" aria-label="Zip code" type="text" name="RF_WC_ZIP" value=""> </div> </div> <div class="row d-flex worker_comp hide justify-content-between"> <div class="form-group col-sm-6"> <label for="adjustor">Adjustor name</label> <input id="adjustor" class="form-control" aria-label="Adjustor name" type="text" name="RF_WC_ADJUSTER" placeholder="First and last name" value=""> </div> <div class="form-group col-sm-4 city"> <label for="adjustor_tel">Adjustor phone</label> <input id="adjustor_tel" class="form-control" aria-label="Adjustor phone" type="tel" name="RF_WC_PHONE" value=""> </div> <div class="form-group col-sm-2 city"> <label for="claim">Claim number</label> <input id="claim" class="form-control" aria-label="Claim number" type="text" name="RF_WC_CLAIM" value=""> </div> </div> <div class="row d-flex worker_comp hide ustify-content-between px-0"> <div class="form-group col-sm-3"> <label for="RF_WC_DATE">Date of injury</label> <input id="RF_WC_DATE" class="form-control datetimepicker_date-only" aria-label="Date of injury" type="text" name="RF_WC_DATE" placeholder="Select date" value=""> </div> <div class="form-group col-sm-9 col-sm-8"> <label for="employer">Employer name</label> <input id="employer" class="form-control" aria-label="Employer name" type="text" name="RF_WC_EMPNAME" value=""> </div> </div> <h4 class="row d-flex px-0 pb-2 pt-4 mb-0 mx-auto"> Attachments </h4> <div class="self-referral mt-3"> <p class="mb-3"><strong>Supporting medical records are required. Lack of attached records or Care Everywhere DOS will result in referral denial.</strong></p> <div class="row d-flex alert alert-form px-4 pt-4 pb-3 align-items-center info-prompt mb-3"> <strong class="pr-5 mb-2">Is your facility or office on EPIC electronic health care system and records can be shared to UC Davis Heath via Care Everywhere? <span class="danger">*</span></strong> <span class="mb-2"> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" name="EPICsystem" id="EPICsystem1" value="1" aria-label="Yes, my facility or office is on EPIC electronic health care system and records can be shared to UC Davis Heath via Care Everywhere" checked=""> <label class="form-check-label" for="EPICsystem1"> Yes </label> </div> <div class="form-check form-check-inline"> <input class="form-check-input hide-section" type="radio" name="EPICsystem" id="EPICsystem2" value="0" aria-label="No, my facility or office isn't on EPIC electronic health care system and records can't be shared to UC Davis Heath via Care Everywhere"> <label class="form-check-label" for="EPICsystem2"> No </label> </div> </span> </div> <div class="EPICsystem mb-3"> <div class="alert alert-form info-prompt p-4 mb-5 mx-auto"> <p class="mb-0" style="font-size: 1rem;"><svg xmlns="http://www.w3.org/2000/svg" width="16" height="16" fill="currentColor" class="bi bi-info-circle mr-2" viewBox="0 0 16 16"><path d="M8 15A7 7 0 1 1 8 1a7 7 0 0 1 0 14zm0 1A8 8 0 1 0 8 0a8 8 0 0 0 0 16z"></path><path d="m8.93 6.588-2.29.287-.082.38.45.083c.294.07.352.176.288.469l-.738 3.468c-.194.897.105 1.319.808 1.319.545 0 1.178-.252 1.465-.598l.088-.416c-.2.176-.492.246-.686.246-.275 0-.375-.193-.304-.533L8.93 6.588zM9 4.5a1 1 0 1 1-2 0 1 1 0 0 1 2 0z"></path></svg>If your facility is using Epic, we can pull your supporting records in Care Everywhere.</p> </div> <div class="row d-flex justify-content-between"> <div class="form-group col-sm-6 required"> <label for="CARE_EVERYWHERE_FACILITY">Care Everywhere facility name</label> <input value="" id="CARE_EVERYWHERE_FACILITY" required class="form-control" aria-label="Care Everywhere facility name" type="text" name="CARE_EVERYWHERE_FACILITY"> </div> <div class="form-group col-sm-6 required"> <label for="SUPPORTING_RECORDS_DOS">Supporting records date of service</label> <input value="" id="SUPPORTING_RECORDS_DOS" class="form-control" aria-label="Supporting records date of service" type="text" name="SUPPORTING_RECORDS_DOS" required> </div> </div> </div> <div class="EPICsystem hide alert alert-form info-prompt p-4 mb-5 mx-auto"> <p class="mb-0" style="font-size: 1rem;"><svg xmlns="http://www.w3.org/2000/svg" width="16" height="16" fill="currentColor" class="bi bi-info-circle mr-2" viewBox="0 0 16 16"><path d="M8 15A7 7 0 1 1 8 1a7 7 0 0 1 0 14zm0 1A8 8 0 1 0 8 0a8 8 0 0 0 0 16z"></path><path d="m8.93 6.588-2.29.287-.082.38.45.083c.294.07.352.176.288.469l-.738 3.468c-.194.897.105 1.319.808 1.319.545 0 1.178-.252 1.465-.598l.088-.416c-.2.176-.492.246-.686.246-.275 0-.375-.193-.304-.533L8.93 6.588zM9 4.5a1 1 0 1 1-2 0 1 1 0 0 1 2 0z"></path></svg>DIRECT Messaging Coming Soon. <a href="https://health.ucdavis.edu/referrals/physician-referral-liaison/index.html" target="_blank">please reach out to your local Physician Liaison to express your interest</a>.</p> </div> </div> <div class="mb-2 px-0"> <strong class="pr-5 mb-2">Attachments (Only PDF and JPEG/JPG files are allowed).</strong> <div class="custom-file no-bottom-radius"> <input type="file" multiple class="file-input" id="notes" name="RF_req_attachment" accept=".pdf, .jpg, .jpeg" aria-label="Upload recent/relevant typed clinical notes/test results (health history, physical, MRI/CT/X-ray results, etc.)"> <label class="custom-file-label" for="notes">Recent/relevant typed clinical notes/test results (health history, physical, MRI/CT/X-ray results, etc.)</label> </div> <div class="file_list notes p-3 hide"><span class="close" aria-label="remove uploaded files" data-value="notes"></span></div> <div class="custom-file insurance no-radius"> <input type="file" class="file-input" id="insurance-card" name="RF_attch_InsCard" accept=".pdf, .jpg, .jpeg" aria-label="Upload copy of insurance card if available"> <label class="custom-file-label" for="insurance-card">Copy of insurance card if available</label> </div> <div class="file_list insurance-card p-3 hide"><span class="close" aria-label="remove uploaded files" data-value="insurance-card"></span></div> <div class="custom-file no-top-radius"> <input type="file" class="file-input" id="hc" name="RF_attch_hcInsAuth" accept=".pdf, .jpg, .jpeg" aria-label="Upload hardcopy of the Insurance authorization (if required)"> <label class="custom-file-label last" for="hc">Hardcopy of the Insurance authorization (if required)</label> </div> <div class="file_list hc p-3 hide"><span class="close" aria-label="remove uploaded files" data-value="hc"></span></div> </div> <p class="form-instructions mt-2 pt-2 px-1 mb-0">This form may contain private, confidential and privileged material for the sole use of the intended recipient. Any reviewing, copying, or distribution of this fax (or any attachments thereto) by anyone other than the intended recipient is strictly prohibited. If you are not the intended recipient, please contact the sender immediately and permanently destroy this fax and any attachments thereto.</p> <p class="form-instructions-top pt-4 mt-3 px-1 mb-0">Please complete this form and submit your referral by clicking the "Submit referral form" button below. You can also print the completed form and submit it via fax to <a href="tel:9167036048">916-703-6048</a> or email to <a href="mailto:hs-referralcenter@ucdavis.edu">hs-referralcenter@ucdavis.edu</a>. If you need technical assistance, please email <a href="mailto:him@ucdmc.ucdavis.edu">Health Information Management</a>. </p> <div class="form-group mt-2 mb-4"> <h4>Acknowledgement<span class="danger">*</span></h4> <div class="form-check form-check-inline required"> <input class="form-check-input" onClick="validateAck(this);" type="checkbox" required name="acknowledgement" id="acknowledgement" value="Yes" aria-label="This is a referral for one of these departments"> <label class="form-check-label pl-5" for="acknowledgement"> By checking this box, I acknowledge that all referrals are reviewed for medical necessity and service line capacity. Submission of referral is not a guarantee of acceptance. To check the status of your referral or ask questions post-confirmation, please <a href="https://health.ucdavis.edu/medicalcenter/cliniclocations/specialtycare/index.html" title="view the specialty department's contact information" target="_blank" style="position:relative; z-index:10;">contact the specialty department</a>. </label> </div> </div> <div class="form-group mt-4"> <input type="submit" disabled="disabled" name="btnSubmitIntake" id="btnSubmitIntake" value="Submit referral form" class="btn btn-primary btn-block" aria-label="Submit referral form"> </div> <div class="form-group mt-4"> <input type="submit" disabled="disabled" name="btnPrintIntake" id="btnPrintIntake" value="Print this form" class="btn btn-outline-primary btn-block" aria-label="Print this form"> </div> <input type="hidden" name="as_sfid" value="AAAAAAVliuCp412YPIBsC-4QrQOPsBWArDhhDTtku8GJgvVclbcg2lhxdhfAwkYdDPSgc7gVRFZciOgBTQ21jL9kVvlQ6Ba1-U_yC1W0yOfVy1mA3JMh1KXl9lla7sAxgpNC0Zj1pPQr_58q0_xcoQ7O-UdYMuIEQxrMShATo6SvVz1ZOA=="> <input type="hidden" name="as_fid" value="8fc7bc4bb946f21a602d79145efc948e1c66b86d"> <script src="https://www.google.com/recaptcha/api.js?render=6LdZYVYfAAAAAERXRDSOHnyZsApn9yfqCWK8_BCg"></script> <input name="g-recaptcha-response" id="g-recaptcha-response" type="hidden" /> <script> //Increasing Recaptcha timeout code modified from https://stackoverflow.com/questions/29908959/increase-recaptcha-session-timeout function reload_recaptcha(grecaptcha) { grecaptcha.execute('6LdZYVYfAAAAAERXRDSOHnyZsApn9yfqCWK8_BCg', {action: 'physRefSubmit_PROD'}) .then(function(token) { document.getElementById('g-recaptcha-response').value=token; }); } function reload_recaptcha_wrapper() { reload_recaptcha(document.grecaptcha); setTimeout(reload_recaptcha_wrapper, 45000); //7.5 min } grecaptcha.ready(function () { document.grecaptcha = grecaptcha; reload_recaptcha(document.grecaptcha); }); setTimeout(reload_recaptcha_wrapper, 45000); //7.5 min </script> </form> </div> </div> </div> </div> </div> <script src="GlobalJS/ucdh-global.js?v=2"></script> </body> </html>

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