Now Taking Physician Referrals This secure form is submitted using SSL technology to ensure the privacy of the personal information you are providing. Please allow 24–48 hours to receive an answer to your request. Referral Form Referring Provider Name * U of U Health or Community Physician? * - Select -U of U Health PhysicianCommunity Physician Office Contact Name * Referring Provider Phone * Referring Provider Fax Number * Referring Provider Email Address * Referring Provider NPI Number * Patient Name (First and Last) * Ï㽶ÊÓƵ of Utah Health Medical Record Number (If Known) * Please submit the form by selecting the 'Submit' button OR call 801-587-3500 Leave this field blank
