Provider Referral Form (for health care professionals only)

Thank you for referring your patient to us. Use the button below or call UK-MDs at 800-888-5533.
REFER A PATIENT
EpicCare Link is the preferred method for submitting online referrals. Previous online referral forms will be taken down in soon. If you currently do not have access to EpicCare Link, please complete an application by clicking here. In order to submit a referral or receive patient notifications, the provider must also have a completed EpicCare Link application on file. For more information, please contact the Physician Liaison Program at 859-323-0736.

Thank you for referring your patient to UK HealthCare. Please fill out and submit the secure form below to begin the referral process. If you are a patient, please use our appointment form.

After you submit this form, you will receive a phone response within 24 hours, excluding weekends and holidays.

Please print this form for your records before you submit it.

You may also refer patients by phone by calling UK-MDs at 859-257-5522 or 800-888-5533.

Referring Provider Information

Provider Request

Request for consult/opinion

Request for referral for care/treatment

UK HealthCare should provide patient appointment information to referring provider

Referring Provider First Name

Middle

Last

Suffix

Degree

Referring Provider Primary Phone

Fax

Email Address

Contact Name

Referring Practice Name

Address

City/Town

State/Province

ZIP/Postal Code

Patient Information

First

Middle

Last

Suffix

Date of Birth

Gender

Male

Female

Other

What is the patient's primary language?

Does the patient need an interpreter?

Yes

If Patient is Under 18, Parent/Guardian Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Patient Primary Phone

Alternate Phone

Other Comments

Insurance Provider

Referral Information

Diagnosis Date

Current Treatment

Request a Specific Physician

Requested Clinic or Service

Treatment Needed

Primary Diagnosis

Onset of Symptoms and Course of Illness

Medications and/or Treatment

Hospitalizations, ER Visits, Other Information

Yes, I would like information about the UK HealthCare referring provider portal.

All e-mail referral forms will receive a phone response within 24 hours excluding weekends and holidays. If you do not receive a response in 24 hours, please call us at 800-888-5533 or in Lexington 859-231-9922.

UK-MDs respects the confidentiality of your personal information and promises only to use it for internal purposes as it relates to this request. By submitting this form, you will transmit your details to us safely over a secure network.

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Appointment

Doctor

MyChart

Provider Referral Form (for health care professionals only)

Referring Provider Information

Patient Information

Referral Information