Submitted On
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UTC
Submitted By
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Submitter Type
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Referral Navigator
Office Representative
This field is required.
Full Provider Name
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NPI
Internal or External
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Internal
External
This field is required.
Hospitalist Only?
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Yes
No
Gender
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Male
Female
Non-Binary
This field is required.
Languages Spoken
Please specify if Fluent, Conversational, or Basic
Education/Training
Hospital Affiliation
Specialty
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Subspecialty
Special Interests
Diagnoses Treated
Please be as exhaustive as possible
Does Not Treat
Please be as exhaustive as possible
Procedures Offered
Please be as exhaustive as possible
Ages Seen
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Adult
Adult and Pediatric
Pediatric
This field is required.
Age Range
*
Allows Video Visits?
No
Yes - New + Est Pts
Yes - Est Pts Only
Yes - By Provider Approval Only
Accepting New Patients?
Yes
By Provider Review
No
Provider Required Imaging
If different from office standard
Provider Required Labs
If different from office standard
Provider Required CPT Codes
If different from office standard
Acceptance Notes
Any other notes regarding patient acceptance (sees female patients only, provider specific testing requirement, etc.)
Accepts Workers Comp?
Yes
No
Accepts Medi-Cals?
Choose an option
Yes - See Insurance Acceptance List
No
Insurance Acceptance
Please be as exhaustive as possible, especially in regards to HMO and Medi-Cal acceptance. If preferable, you may email a Contracted Payor List to [email] and note "CPL Emailed" in the box below.
Provider Scheduling Out To
Please provide the month and year
Provider Days In Office
Office Name
*
Please format as "Office Name - City"
Add New Office Information
For existing office updates, please use the update form
Office Insurance Acceptance
Please be as exhaustive as possible, especially in regards to HMO and Medi-Cal acceptance. If preferable, you may email a Contracted Payor List to [email] and note "CPL Emailed" in the box below.
Office Required Imaging
Please specify if imaging is diagnosis specific
Office Required Labs
Please specify if labs are diagnosis specific.
Office Required CPT (Procedure) Codes
Additional Office Information
Please include any additional information you'd like us to know such as parking info, office specialization, etc.
Provider has multiple locations
Office 3 Specific Info
e.g. If any imaging, lab, or procedure codes are required unique to this office, as well as any additional information you'd like us to know such as parking info, office specialization, etc.
Centralized Scheduling Phone Number
Centralized Referral Phone Number
Centralized Referral Fax
Receives Rfls Via
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EPIC
Care Everywhere
Direct Secure Messaging
Sutter Community Connect
Sutter Link
Fax
This field is required.
Accepts Self-Referrals?
Yes
No
Referring Restrictions
e.g. Must come from general ophthalmologist, Must come from PCP, etc.
Any Other Notes
Please provide any information that does not fit in categories above
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