The UCSF patient referral form is a one-page document a referring provider completes to request a specialist consultation at UCSF Health. It collects patient demographics, insurance details, a diagnosis with its ICD code, and the reason for the visit. You can submit it three ways: through the auto-filling web form at refer.ucsfhealth.org, as a downloadable PDF sent by fax, or through UCSF’s secure MD Link portal for offices that refer regularly.1UCSF Health. Refer a Patient
Which Version of the Form to Use
All three versions start from the UCSF Health “Refer a Patient” page.1UCSF Health. Refer a Patient
- The online web form auto-fills some fields after you select the referring provider, which cuts down on data entry errors. Fastest for a one-time referral.
- The downloadable PDF is the standard fax form. Print, complete, and fax it in. Useful when you need to attach printed records or your office doesn’t use the digital options.
- MD Link is a secure portal for providers who refer to UCSF regularly. It allows online referrals and order placement.
For adult cancer patients, use the separate cancer referral form from the Cancer Services Referral Center page rather than the general form.2UCSF Health. Cancer Services Referral Center Some UCSF Benioff Children’s Hospital clinics follow a different referral process, so check the specific clinic’s page in the Benioff directory before submitting a pediatric referral.3UCSF Benioff Children’s Hospitals. Refer a Patient: Pediatric Primary Care Clinic
What the Form Asks For
The form has three sections. Missing fields are the most common reason referrals stall, so work through each carefully.
Patient Information
Full name, date of birth, home phone, work or cell phone, and mailing address with zip code. If the patient is a child, include the parent’s name. Check the interpreter box if one is needed and note the preferred language. On the insurance line, list the plan and attach copies of both sides of the insurance card. For HMO plans that require authorization, include the HMO authorization number or letter.4UCSF Gastroenterology. UCSF Health Referral Form
Consultation Request
This is the clinical core. Enter the diagnosis with its ICD code, the UCSF specialty, and the specific reason for the consultation. If you already have a UCSF physician in mind, there’s a field for that too. The form’s printed instruction is to “include brief pertinent medical records, including test results that support the consultation.”4UCSF Gastroenterology. UCSF Health Referral Form That means recent office notes, labs, imaging reports, or pathology results relevant to the condition, so the specialist has enough context to evaluate urgency and plan the first visit.
Referring Physician Information
Name, specialty, phone, fax, and signature of the referring physician, plus a separate line for the patient’s primary care physician if that’s a different person. The referring provider’s signature includes consent for UCSF to initiate treatment or order medically necessary diagnostic tests in connection with the consultation.4UCSF Gastroenterology. UCSF Health Referral Form
What to Attach
A bare form usually isn’t enough for the intake team to schedule appropriately. Attaching supporting documents upfront prevents back-and-forth that can delay the appointment by days or weeks.
- Both sides of the insurance card, plus the prior authorization letter or reference number if the plan is an HMO.
- Recent office visit notes covering the last few relevant appointments.
- Labs, imaging reports, or pathology results tied to the diagnosis. For complex imaging cases, sending the actual study files gives the UCSF team more to work with than the radiologist’s report alone.
- A letter of medical necessity if the insurer requires one. A strong letter documents the primary diagnosis with its ICD-10 code, treatments already attempted and why they were insufficient, and the clinical reasoning for UCSF specialty care.
Keep copies of everything you send. If a document goes missing in transmission, you can resend from the original rather than starting over.
Where to Send It
Most specialties go to the UCSF Referral Center:
- Phone: 800-444-2559
- Fax: 415-353-4395
- Email: referral.center@ucsf.edu
- Hours: Monday through Friday, 8 a.m. to 5 p.m. Pacific time
The referral center staff can help you identify the right UCSF specialty or physician if you’re unsure.5UCSF Health. Physician Referral Services
Oncology referrals go to the dedicated Cancer Services Referral Center at 877-UCSF-CAN (877-827-3226), fax 415-514-8253, same weekday hours.2UCSF Health. Cancer Services Referral Center
Patients outside the United States go through UCSF International Services, which assigns a patient liaison to coordinate care from first contact through follow-up. Phone: +1 415-353-8489. Fax: +1 415-353-3672. Email: international@ucsf.edu.6UCSF Health. International Services
Insurance and Prior Authorization
Whether the patient’s plan requires prior authorization before a UCSF visit depends on the plan type. PPO plans and UC Care typically do not require it for specialty visits. HMO, POS, EPO, and IPA plans almost always do. County health plans and Medi-Cal plans vary. UCSF Health is not contracted with Kaiser Permanente HMO, though Kaiser occasionally authorizes out-of-network referrals case by case.7UCSF Eating Disorders. Insurance Coverage and Authorization
If authorization is required, obtain it before submitting and include the authorization number on the form. Submitting without it doesn’t necessarily stop UCSF from processing the referral, but it can delay scheduling and create billing complications later.
Patients covered under UC SHIP need a referral from UCSF Health Primary Care for any specialty visit, including follow-ups, for the plan to pay the claim.8UCSF Student Health and Counseling. Specialty Care Coordination and Referrals Some plans set expiration periods on referrals, after which a new authorization is needed. Check the patient’s specific plan; there is no universal standard.
What Happens After You Submit
Once UCSF receives the referral, the intake team reviews the form and attached documents, then the patient or referring office is contacted to schedule.
California law sets maximum wait times for health plan members to see a specialist once a referral is made. Under Health and Safety Code section 1367.03, urgent appointments that don’t require prior authorization must be offered within 48 hours of the request. Urgent appointments that do require prior authorization must be offered within 96 hours. Non-urgent specialist appointments must be offered within 15 business days.9California Legislative Information. California Health and Safety Code 1367.03
These timelines govern what the health plan must make available. They can be extended if the referring or treating provider determines in writing that a longer wait won’t harm the patient, and they don’t apply to self-pay patients or plans outside DMHC jurisdiction.10Legal Information Institute. Cal. Code Regs. Tit. 28, 1300.67.2.2 – Timely Access to Non-Emergency Health Care Services For DMHC-regulated plans, the DMHC Help Center at 1-888-466-2219 can assist patients having trouble getting timely access after a referral has been submitted.
If the Referral Is Denied
Insurers sometimes deny referrals, usually on medical necessity grounds or because an in-network alternative exists. The first step is an internal appeal. Federal law gives patients 180 days from the date they receive the denial notice to file one.11HealthCare.gov. Appealing a Health Plan Decision
A strong appeal typically includes a letter of medical necessity from the referring physician documenting the diagnosis with its ICD-10 code, the specific treatments already tried and why they failed, objective clinical evidence supporting the need for UCSF specialty care, and the expected clinical outcome of the requested consultation. Citing the insurer’s own clinical policy guidelines and explaining why the patient meets them carries more weight than a general necessity statement.
If the insurer upholds the denial after the internal appeal, patients have the right to request an external review by an independent third party under the Affordable Care Act. The reviewer’s decision binds the insurer. States with external review processes that meet federal standards run their own programs; where they don’t, HHS administers the process or requires the insurer to contract with accredited independent review organizations.12CMS. External Appeals