Need Assistance?
Physician Helpline: 866-742-4811
Referral Request Form
(Items with ** are required for processing)
Fax To: 650-320-9443 or Submit online using
Radiology Referrals / Orders: Use Form: https://stanfordhealthcare.org/imaging
Patient Information Reason for Referral
If Medical Records Cover Sheet is included,
Patient information can be left blank
Priority: Routine ☐ Medically Urgent ☐
Name (First, Middle, Last)** Sex: ☐ Male ☐Female
If Medically Urgent, please describe:
Date of Birth**
Diagnosis/ICD 10**
Phone # ** Secondary Contact #
Clinic / Specialty Requested**
Address**
Physician Requested Location Requested
City** Zip Code** State
If Requested Physician is Unavailable,
Can Patient be seen by another provider?
☐ Yes ☐ No ☐ Contact Referring Provider
Interpreter Needed? Yes ☐ No ☐
Preferred Language:
☐ Consultation ☐ 2
nd
Opinion ☐ Procedure
☐ Other
Referring Provider Information
Referring Provider Name**
PCP Name
Practice Name**
Office Address**
City**
State**
ZIP Code**
NPI Number
Phone**
Fax**
Provider Specialty
Documentation Requested
☐ Relevant Clinical Notes (History & Physical, Imaging and Lab results)
☐ Copy of Insurance Card ☐ Insurance Authorization Information (If required)
