Division of Rheumatology New Patient Referral - UCLA Health

Please enter all required information below. One of our friendly staff will contact you within 24 - 48 hours. You can also call our office at (310) 825-4357.

For patients with HMO coverage to be seen at the venous center, an insurance authorization is required from their primary care referring physician. With a patient's consent, a copy of the consultation note will be forwarded to the referring physician.

Referring Physician Information

Physician's Name *

Address (complete) *

Phone Number *

Fax Number

Email Address

Contact Information of Person Completing Form

Full Name *

Phone Number *

Email Address *

Patient Information

First Name *

Last Name *

Phone Number *

e.g (123-456-7890)

Email Address *

Date of Birth *

MM/DD/YYYY

Gender *

Diagnosis or Illness (specify) *

Is There a Specific UCLA Rheumatologist You Are Requesting?

Preferred Location *

Westwood

Santa Monica

Insurance Authorization Number (if applicable)

Comments

INSTRUCTIONS: Please fax any available medical records to (310) 794-6553 for Westwood office or (310) 582-6352 for Santa Monica office. To facilitate processing, please fax the front and back of patient's insurance card, if available.

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