Online Physician Referral Form

A talented staff of physicians, nurses, therapists, technologists, and other health care professionals bring expertise to every aspect of patient care at the University Of Illinois Hospital & Health Sciences System. Our goal is to make your referrals to UI Hospital as easy as possible for you and your patient. The University Of Illinois Hospital & Health Sciences System has been moving medicine forward for the benefit of the people of Illinois and beyond since 1859. The Medical Center includes a 495-bed tertiary hospital, an outpatient facility, specialty clinics, the UIC College of Medicine, and five other health science colleges. More new physicians earn their medical degrees here than at any other medical school in the country. As a leader in patient care, research and education, UI Hospital is committed to changing medicine and changing it for good.

* Required Fields

Referring Physician Information

Remember Physician Information.(?)
Physician's First Name: *
Physician's Last Name: *
Clinic Name:*
Clinic Address:*
NPI Number: *
City: *
State: *
Zip Code: *
Clinic Phone: *
Clinic Fax: *
Contact Name:*
Contact Phone:*
E-mail Address: *

Patient Information

Patient's First Name:*
Patient's Last Name:*
Date of Birth (mm/dd/yyyy):*
Primary Number: *
Altername Number: *
Best time to contact patient:*
Reason for diagnosis:*
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Patient List

First Name	Last Name	Date of Birth	Primary Phone	Alternate Phone	Best time to contact	Diagnosis	Specialty Requested

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University Of Illinois Hospital & Health Science System — Changing medicine. For good.

Online Physician Referral Form

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University of Illinois Hospital & Health Sciences System

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