Specialty Requested: *
Please choose a specialtyAllergyCardiology / CV Surgery / Congenital HeartDiabetes Resource CenterEndocrinology (non-Diabetes)ENT (Otolaryngology)GastroenterologyHealthy Kids U / Weight Management / Eating DisordersHematology / Oncology / Sickle Cell肾脏学Neurology / EpileptologyOphthalmologyOrthopedicsPalliative CarePulmonology / Sleep Medicine / Home Vent ProgramSurgery / Congenital Diaphragmatic Hernia ClinicUrology / Spina Bifida Clinic

Preferred Provider's Name:
Is there a specific provider you want this patient to see?

Priority of Referral: *

• STAT – PLEASE CALL
• Same day/Urgent/ASAP/Today – PLEASE CALL
• Less than 3 days – PLEASE CALL
• Less than 1 week
• Less than 2 weeks
• Less than 3 weeks
• Less than 4 weeks
• Routine

Has patient been to an OSF facility before: *

• Yes
• No, or unsure

Patient Information

First Name: *

Last Name: *

Date of Birth: *

Gender:

Address:

City:

State:

ZIP:

Phone Number: *

Alternate Number:

Email Address:

Guardian Information

Full Name of Parent or Guardian: *

Relationship to patient: *

Phone Number (if different than above):

Is patient/family aware of referral?
YesNo

Is the patient currently in DCFS custody?

• Yes, the patient is currently in DCFS custody

Special Needs (select all that apply): *

• None
• Hearing impairment
• Vision impairment
• Needs interpreter (include options – which language or ASL)
• Needs wheelchair
• Needs transportation
• Other

If "other," please explain.

Insurance

Insurance Company:

Policy Number:

Customer Service Phone Number:

Policy Holder Name:

Policy Holder Date of Birth:

Referring Provider

Referring Provider Name: *

NPI:

Phone: *

Fax Number:

Appointment Details

Reason for Appointment: *

Records

Records will be sent by (pick one). *

• Attachment
• Fax (Fax number & cover sheet in confirmation email)
• Mail
• Epic/Care Everywhere
• elink

Please attach records here:
Combined file sizes cannot exceed 15MB

Additional Attachment:
Combined file sizes cannot exceed 15MB

Additional Attachment:
Combined file sizes cannot exceed 15MB

Additional Attachment:
Combined file sizes cannot exceed 15MB

Confirmation email can be sent to: