Provider Referral Form (for health care professionals only)

Thank you for referring your patient to UK HealthCare. EpicCare Link is the preferred method for submitting referrals. It significantly expedites the referral process by going directly into the scheduling work queue and is less time consuming and easier to submit.

If you do not have EpicCare Link access, please contact your Link Site Administrator at your location or request access. In order for staff to be able to submit referrals and for patients to be connected back to your practice, each provider needs a completed EpicCare Link application even if they are not going to utilize the system. It can take up to three weeks for new user applications to be processed. Once IT has set up your account, your log in credentials will be emailed to you. In the interim, you can continue to use the form below or call UKMDs at 800-888-5533; however, the plan is to discontinue faxing and the web-based referral form once users are set up on EpicCare Link.

For more information regarding EpicCare Link, please download this PDF or contact the Physician Liaison Program at 859-323-0736.

EpicCare Link Log In EpicCare Link Access Request

If you do not have EpicCare Link access, please fill out and submit the secure form below to begin the referral process. If you are a patient, please use our appointment form.

Please allow three business days for processing this web-based referral form. Patients will be contacted directly for scheduling. For faster processing, please utilize EpicCare Link.

You may also refer patients by phone by calling UKMDs at 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

Please allow three business days for processing this web-based referral form. Patients will be contacted directly for scheduling. For faster processing, please utilize EpicCare Link.

If you need to check the status of this referral, please call UKMDs at 800-888-5533. EpicCare Link users are able to check the referral status in real-time and view upcoming patient appointments.

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

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