Electronic Referral Form Checklist | Patient Referrals | UC Davis Health

Please include the following with your referral:

• Completed UC Davis Health electronic referral intake form
• Recent, relevant clinical notes and test results (e.g., history, physicals, imaging, labs)
• Proof of insurance
• Authorization details (approved CPT codes, number of visits, and valid dates)

For Self-Referrals:

• Patients may submit a self-referral if they:
  • Have a PPO Insurance Plan
  • Are paying cash for care
  • Have insurance that allows self-referral to specialty care
• To submit a self-referral to UC Davis Health, please complete the electronic referral intake form. Your referral will then be sent to the appropriate specialty department for review.
• When completing the electronic intake form:
  • Select ‘Yes’ for ‘Is this a self-referral?’
  • Complete all required self-referral information
  • Submit the form for review
• If you have any questions, please contact the Patient Contact Center: 800-4-UCDAVIS or 800 482 3284

Important Notes

• Incomplete or unclear information may delay processing
• Urgent self-referrals are not accepted. Patients must obtain an urgent referral from their primary care provider.