Refer a Patient: Transgender �����г���Ƶ Program

Now Taking Physician Referrals

For more information, please refer to our:

,
, and
.

Referring a Patient to the Transgender ��г��Ƶ Program

Thank you for referring a patient to ��г��Ƶ of Utah ��г��Ƶ Transgender ��г��Ƶ Program. If you are a ��г��Ƶ of Utah ��г��Ƶ provider, please create a referral order for CN0391 AMB — Referral to Transgender ��г��Ƶ in Epic. Also, please leave the reason why you are referring the patient and the services being requested by the patient in the comments section of Epic.

If you are an outside provider, please fill out this form below and click “Submit”. We will contact you in 1-2 business days.

Referring Provider Information

Full Name Of Referring Physician: ^*

Full Name Of Requested Provider: ^*

Referring Practice Name:

Referring Practice Address:

City:

State:

ZIP Code:

Referring Office Contact: ^*

Referring Provider Email:

Referring Provider Fax: ^*

Referring Provider Phone Number: ^*

Referring Provider NPI Number: ^*

Patient Demographics

Legal Name: ^*

Preferred (Chosen) Name: ^*

Date of Birth: ^*

Pronouns (I.E. She/Her/Hers, They/Them/Theirs, Etc.):

Gender Identity:

Sex Assigned At Birth:

Male

Female

Intersex

Other

Mailing Address:

City:

State:

ZIP Code:

Phone Number:

Email Address:

Sex Indicated On Insurance:

Male

Female

Name Indicated On Insurance:

Plan Name:

ID#:

Self-Pay (Optional):

Interpreter Needed?:

Yes

If You Answered Yes To An Interpreter, What Language?:

Medical Information

Primary Diagnosis Code: ^*

Is Patient Taking Hormones?:

Yes

If Patient Is Taking Hormones, What Type?:

Patient's BMI:

If Other Service Requested, Please Specify:

�����г���Ƶ