Refer a Patient Form

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Department

Please download and complete Sleep Study and Sleep Medicine Service Request. Fax form and clinical records to 317.968.1305 or upload as part of submission. Please note, a signature from the referring provider is required when submitting Sleep Study and Sleep Medicine Service Request.

Please fax clinical records to 317.968.1305 or upload as part of submission.

Please fax clinical records to 317.948.5473 or upload as part of submission.

Please fax clinical records to 317.968.1028 or upload as part of submission.

Requested provider

Appointment note

Urgent First Available

Call 1.844.MyRiley (1.844.967.4539) for urgent consults.

If the patient needs to be seen within the next 72 hours, please contact the Riley department directly.

Reason for referral/specific medical concern:*

Gravida

LMP

EDC

LMP/US

Date of first ultrasound

Gestational age at first ultrasound

Social/Cultural needs?

Transportation needs

Yes No

Patient Information

Patient first name*

Patient last name*

Date of birth*

Sex assigned at birth*

Gender identity

Additional identity

Last four digits of social security number

Parent/guardian name* (if under 18 years of age)

Street address*

City*

State*

ZIP code*

Home phone*

Cell phone

Work phone

Due to COVID-19, our specialists will conduct virtual visits when appropriate. Please list patient's email address:*

Patient does not have an email address

Does the patient need an interpreter?*

Yes No

Language/Dialect Needed

Medical Records

IU Health provides a file upload option to conveniently and securely upload medical records during a referral.

If you are unable to upload the file here, you can fax them at the number shown on the confirmation page to this form. File types accepted: .pdf, .tif

* File uploads may not work on some mobile devices.

File 1

File 2

File 3

Insurance Information

Does patient have insurance?*

Yes, patient has insurance No, patient does not have insurance

Guarantor name*

Date of birth*

Insurance provider*

ID number*

Group number*

Referring Physician

Referring physician*

Referring physician National Provider Identifier (NPI)*

Contact person*

Email address

Secure direct messaging address

Office phone*

Office fax*

Primary physician (if different than referring physician)

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Legal notice information:
Confidentiality Notice: The information contained on this form may be confidential and legally privileged. It is intended only for use of the individual or entity named. If you are not the intended recipient, you are hereby notified that the disclosure, copying, distribution, or taking of any action in regards to the contents of this form – except its direct delivery to the intended recipient – is strictly prohibited. If you have received this form in error, please notify the sender immediately and destroy this form along with its contents, and delete from your system, if applicable.

Refer a Patient Form

Patient Information

Medical Records

Insurance Information

Referring Physician

About our process