Request For Consultation University Of Michigan Health System
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2Department of Internal Medicine
Division of Rheumatology
1500 E. Medical Center Drive
Ann Arbor, MI 48109-5358
M-LINE: 1-800-962-3555
Clinic: 734-647-5900
Fax: 734-936-8067
REQUEST FOR CONSULTATION
PLEASE COMPLETE FORM AND FAX TO 734-936-8067. Missing information may delay the referral process.
Today’s Date:__________________________ Contact Name & Number:__________________________________
UM Registration #: (Internal use only)_________________________
Section 1: Patient Information
__________________________________________________________
Patient Name:
(PLEASE PRINT)
_________________________________
___________________________
Address:
City/State/Zip:
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___________________________
Date of Birth:_____/_____/_______
Sex: F
M
Social Security
_________________________
_________________________________
Telephone #s: (home)
(work)
Patient’s Insurance (REQUIRED):
If referral authorization is required, please fax it to 734-936-8067.
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M-CARE
BCN
BCBS
Medicaid
Other _____________________
HMO
POS
PPO
Section 2: Physician Information (REQUIRED)
__________________________________
__________________
UPIN #
Referring Physician’s Name:
__________________________________
____________________________
Address:
City/State/Zip:
_______________________________
________________________________
Telephone #:
Fax #:
_______________________________
__________________
UPIN #
Primary Care Physician’s Name:
__________________________________
____________________________
Address:
City/State/Zip:
:_______________________________
________________________________
Telephone #
Fax #:
Section 3: Patient History Information (REQUIRED)
Diagnosis: _________________________________________________________________________
Rule Out: __________________________________________________________________________
To avoid duplication of tests, please list relevant studies and date completed: Fax reports if not performed at U of M
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Location:_____________________
X-Ray (list type)____________________
Date: ____/____/_____
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Location:_____________________
MRI (list type)_____________________
Date: ____/____/_____
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Location:_____________________
Other (list) ________________________
Date: ____/____/_____
Please give a brief description of patient’s medical history:
Comments:
For UMHS Use Only: UMHS Rheumatology Physician Recommendation
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Emergent – Refer to consult team
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Urgent – Schedule within _________ weeks
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Non-urgent – Schedule within __________ months
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Schedule with Dr. ______________________________
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Schedule in _______________________________ clinic
Please fax consultation request form and medical documentation to (734) 936-8067.
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