Refer a Patient: Liver Transplant

Now Taking Physician Referrals

Complete the web form below to refer a patient. You will receive an email confirmation from our team to confirm your receipt. We will also ask you to share additional patient information.

If you prefer, you can fax your referral to 801-585-5091.

Referring Provider Information

Referring Clinic Name:

Referring Provider Name

Address

City

State

ZIP/Postal Code

Referring Provider Contact Person

Referring Provider Phone Number

Referring Provider Fax Number

Referring Provider Email Address

Patient Information

First Name

Last Name

Date of Birth

Address

City

State

ZIP/Postal Code

Contact Person (If not Patient)

Relationship to Patient

DX Associated with Liver Transplant:

Daytime Phone Number

Insurance

Patient Information Needed

The following information, if available, will be requested at the time of referral:

Patient demographics, including current insurance information
Two years of medical records from all attending physicians and specialists
History and physical
Lab work
Radiology reports
Pathology report, including liver biopsy if available
Surgery and procedure reports, including EGD, Colonoscopy, pap smear, and mammogram, if applicable
If there is a history of drug or alcohol abuse, the patient will need to provide documentation of six months of attendance in a relapse prevention program, such as alcoholics anonymous, or private inpatient or outpatient treatment and results of six months of random drug and alcohol screens from referring physicians.
Immunization records
A letter from your dentist stating that all dental work has been completed and that no further dental treatment, other than teeth cleaning, should be required for one year.

Please fax your referral to 801-585-5091 or use the online form.

�ǿմ�ý