Please fill out the referral form on the right and click 'SUBMIT' when finished.

If you have any questions, please don't hesitate to contact us at 801-563-5121.

Thank you for your referral.

Uma Karnam MD
Gastroenterology and Hepatology

If the patient's insurance company requires a referral, we will need your office to request one. Our scheduling department will call your patient within 1 business day of receiving your referral to schedule the procedure and/or office visit. Our staff will also recertify the procedure and forward the consult report or procedure report to your office as soon as it is completed.

PLEASE SEND US A COPY OF ANY PERTINENT OFFICE DICTATION AND/OR TEST RESULTS (LAB/X-RAY)
Patient Referral Form


PATIENT NAME:  
DATE OF BIRTH:  
     
HOME ADDRESS:  
CITY:  
STATE:  
ZIP:  
     
PHONE #:  
OTHER PHONE #:  
     
SOCIAL SECURITY #:  
     
INSURANCE COMPANY NAME:  
INSURANCE POLICY #:  
INSURED'S NAME:  
INSURED'S DATE OF BIRTH:   
     
TYPE OF APPOINTMENT  REQUESTED:    
   
                  		 
     
REASON FOR REFERRAL:  
COMMENTS / NOTE:  
     
PRIMARY CARE PHYSICIAN:  
PHONE #:  
NPI #: