Refer A Patient to Otolarygnology

Now Taking Physician Referrals

To refer your patient, please fill out the form below and click on the button labeled "Submit." We will contact you within 24-48 hours.

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Providers Outside University of Utah �ǿմ�ý

Fax voice disorder referrals to 801-587-3569. Fax otolaryngology and audiology referrals to 801-585-2500.

Referring Provider Information

Referring Provider Name

Referring Office Contact

Referring Department

Referring Provider Phone Number

Referring Provider Fax Number

Referring Provider Email Address

Referring Provider NPI Number

University of Utah �ǿմ�ý Physician or Community Physician?

Referring To

Patient Information

First Name

Last Name

University of Utah �ǿմ�ý Medical Record Number (If Known)

Date of Birth

Address

City/Town

ZIP/Postal Code

Please help us understand your patient's medical history. Has your patient had any of the following tests?

Audiogram

No

Yes

Date of Audiogram

CT

No

Yes

Date of CT

MRI

No

Yes

Date of MRI

Other Testing

No

Yes

Name and Date of other testing

Would You Like to Request a Specific Provider?

No

Yes

Please provide the name of the provider

Urgency Rating

Primary Insurance Information

Policy Number

Policy Holder

Phone Number

Insurance Provider

Secondary Insurance Information

Policy Number

Policy Holder

Phone Number

Insurance Provider