Universal Healthcare Provider Network, a division of Universal Care Universal House, 15 Tambach Road, Sunninghill Park, Sandton 2191

PO Box 1411, Rivonia 2128Telephone: +27 11 208 1000 / Fax: 0862 957 355 / www.universal.co.za

Initials:Member’s surname:

Doctor’s name:

Contact details: Treatment date:

Secondary ICD10 code:

DATE

Patient date of birth:

Practice no.:

DOCTOR SIGNATURE

D D M M Y Y Y Y

UNIVERSAL NETWORK SPECIALIST REFERRAL FORM

Initials:Patient surname:

Membership no.:Medical scheme:

Primary ICD10 code:

Doctor’s name:

Contact details:

Authorisation no.:

Date of appointment:

Practice no.:

NB:

1. Members must contact (011) 208-1100 for prior authorisation2. Members are to ensure that the referral form from the General Practitioner is handed to the specialist on the day of the visit3. The authorisation number must appear on the specialists account4. Accounts are to be submitted to the Medical Scheme

Make a diagnosis: Perform a procedure: Suggest a treatment: Consider an admission:

MEMBER’S DETAILS:

REFERRING GENERAL PRACTITIONER:

SPECIALIST REFERRED TO:

INDICATE DESIRED INPUT FROM THE SPECIALIST:

DETAILED REASON FOR REFERRAL:

Patient ID no./Passport no: