Referral Request

Upon completion of this request, we will contact the patient within 24 hours to assist with making an appointment. You may fax medical records or radiology orders to (312) 947-2299 or email the Access Navigator Team at facilitated_access_navigators@rush.edu.

You may also contact the Provider Express Line directly by calling (312) 947-4725.

Web Form Detail:

Referring Provider Information

First Name

Middle Initial

Last Name

Email Address

Phone Number

Fax

Preferred method of communication regarding referral


 

Patient Information

First Name

Middle Initial

Last Name

Date of Birth

Phone Number

Appointment Information

Referral Specialty

Reason for Referral

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