Patient Transfer and Referral Form

Physician Access Services is UC San Diego Health System's single point of access for referrals to specialists and services.

To refer or transfer a patient, fill out this form or call the Physician Access Line at 855-543-0555.


Patient Information

(xxx-xxx-xxxx)
Year - XXXX

Referring Provider Information

(xxx-xxx-xxxx)
(xxx-xxx-xxxx)

Billing and Insurance Information

* indicates a required field