Physician Referral

To refer a patient for an appointment, please complete the form below and your patient will be contacted for scheduling. Fax referral forms may be sent to 303.270.2162.

You may also contact our Physician Line at 1.800.652.9555, Monday - Friday, 8:00 am to 5:00 pm Mountain Time or physicianline@njhealth.org.

For mycobacterial disease referrals, complete the Mycobacterial Referral/Consult form.

Other resources: Order a test | General Physician Consults | Radiology Consult

Provider Information

Provider First name

Provider Last Name

Name of requesting office or facility

Type of practice

Provider Country

Provider International Address

Provider International Phone number

Provider Fax

Provider Email address

Is this a referral for pediatric behavioral health?

If yes, please select:

Patient Information

Patient First name

Patient Last name

Patient Gender

Female
Male
Transgender

Patient Date of Birth

Patient Age

If child, parent's/guardian's name

Patient Country

Patient Address

Patient Phone Number

Have you previously contacted National Jewish Health about this patient?

DX and Brief history
(Please include something in addition to the ICD9 code)

Medications