Physician Referral Form

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

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

Other resources: Order a test | General Physician Consults | Mycobacterial Referral/Consult

Provider Information

Provider First name *
Provider Last Name *
Type of practice
Provider Country * 
Provider International Address *
Provider International Phone number *
Provider Fax  
Provider Email address * 
Patient Information
Patient First name *
Patient Last name *
Patient Gender * 
Patient Date of Birth *  
Patient Age  
If child, parent's/guardian's name
Patient Country * 
Patient International Address *
Patient International Phone Number *
Have you previously contacted National Jewish Health about this patient? * 
Medical concern for which you would like the Patient to be seen. (Please include something in addition to the ICD9 code) *
Medications *
Other medical problems
Insurance Carrier/ ID *

PLEASE NOTE: Our system does not accept attachments. If you attempt to attach a document, the information will not be processed.

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