Patient Referral Form for Orthopedics & Sports Medicine

Please contact 317.944.9400 with any questions. Fax clinical records to 317.963.2644 or upload as part of submission.

Appointment Note

e.g., first available, specific physician

Requesting

Consult Consult & Treat Consult & Ongoing Care Second Opinion

Other:

Reason for Referral / Specific Medical Concern / Diagnosis*

Right, Left, Bilateral, or Not Applicable*

Patient Information

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Number

Patient sex assigned at birth*

Patient gender identity

Additional identity

Last Four Digits of Social Security Number*

Parent / Guardian Name*

if under 18 years of age

Address*

City*

State*

ZIP Code (5 digits)*

Primary Phone Number*

(999) 999-9999

Primary Phone Type

Mobile Home Work

Secondary Phone Number

(999) 999-9999

Secondary Phone Type

Mobile Home Work

Email Address

Does the patient need an interpreter

Yes No

Language Needed*

Medical Records

IU Health provides a file upload option to conveniently and securely upload medical records during a referral.

If you are unable to upload the file here, you can fax them at the number shown on the confirmation page to this form.

Filetypes accepted: .pdf, .tif, .jpg, .jpeg, .gif, .png, .bmp, .doc, .docx, .csv, .xls, .xlsx, .txt

* File uploads may not work on some mobile devices.

A maximum of 3 files may be uploaded.

File 1

No File Chosen

File uploads may not work on some mobile devices.

File 2

No File Chosen

File uploads may not work on some mobile devices.

File 3

No File Chosen

File uploads may not work on some mobile devices.

Insurance Information

Self Insured?

Yes No

Guarantor Name

Date of Birth

Insurance Provider

ID Number

Short Answer

Group Number

Short Answer - Copy

Referring Physician

Referring Physician*

Contact Person

Preferred communication method for follow-up to referring office

Email Address Direct Messaging Phone Fax

Office Phone*

(999) 999-9999

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Office Fax*

(999) 999-9999

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Email Address

for submission confirmation

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Secure Direct Messaging Address

Primary Physician

if different than referring physician

About Our Process

After the referral and clinical records are received, our referral coordinators will contact the patient or parent/guardian to schedule an appointment. Once an appointment is set, we will contact the referring office with appointment information. If we cannot contact the patient or parent/guardian after three attempts, we’ll inform the referring office and the patient that the referral has been closed. Following the appointment, we’ll also confirm that clinical notes have been provided to the referring office.

Please contact 317.944.9400 with any questions. If additional information is required for your referral, someone from the IU Health Physicians Referral Services will contact you.

Legal notice information:
Confidentiality Notice: The information contained on this form may be confidential and legally privileged. It is intended only for use of the individual or entity named. If you are not the intended recipient, you are hereby notified that the disclosure, copying, distribution, or taking of any action in regards to the contents of this form – except its direct delivery to the intended recipient – is strictly prohibited. If you have received this form in error, please notify the sender immediately and destroy this form along with its contents, and delete from your system, if applicable.

Status

Notes