Refer a Patient
Steps for Submitting a Telehealth Referral
- Complete a Telehealth Referral Request Form — Fax the form to (866) 622-5944 or submit via email along with any documentation outlined in the referral guidelines. For specialties not listed, please provide as much documentation as possible to assist us in securing a one-time consultation.
- Confirmation Call — A telehealth coordinator will call you to schedule your appointment.
- Consultation Instructions — We will provide instructions on how to connect for your consultation. We ask that all sites test the connection prior to the appointment date to ensure good audio/visual quality and review the use of any external telehealth peripherals that might be needed during the consultation.
- Confirm the Appointment — Notify your patient two business days prior to the consultation date.
- Complete Paperwork — Provide your patient with a copy of our Notice of Privacy Practices and fax a signed copy of our Acknowledgement of Receipt form to (866) 622-5944 before the consult. Document your patient's verbal consent to participating in a telehealth consultation in your patient's chart/electronic record.
Information and Forms
- Do's and Don'ts for a Remote Site (PDF)
- ENT Questionnaire (PDF)
- Medicare Secondary Payer Questionnaire (Word)
- MIND Patient Questionnaire (PDF)
- Notice of Privacy Practices - English (PDF)
- Notice of Privacy Practices - Spanish (PDF)
- Acknowledgement of Receipt - English (PDF)
- Acknowledgement of Receipt - Spanish (PDF)
- Patient Satisfaction Survey (PDF)
- Provider Satisfaction Survey (PDF)
- Telehealth Referral Request Form (PDF)
"There are several innovative telehealth models of care that UC Davis Health is pioneering that will transform the way in which we deliver care in the future."
— James Marcin, M.D., Director, Center for Health and Technology