Professional Master Referring Physician Update Form

Physician Referral Services
PhysicianReferralServices@uams.edu
Phone: 501-686-7831
Fax: 501-686-6013

  NOTE: * fields are required
Date * 3/18/2010 6:58:06 AM
From:    Name: *
Dept: *
Phone *
Fax *
Email *
   
Request addition/change to the Medipac system for the following Referring/PCP Physician
Physician Name:   Last Name
 *
First Name *
Middle Initial
M.D. Link Authorization
Physician ID Number (UPIN#)
Office Address:   Street
City *
State *
Zip *
   
Referred Patient Name *
Referred Patient Account Number: *
United HealthCare Number:
   
Note: