International Patient Program – West Virginia University Hospitals

Referral Form

If you wish to be referred to WVU Hospitals, please complete and submit this referral form.

Your form will be reviewed by a physician in the specialty you are requesting referral to.

You can submit the form by faxing it to 1-304-598-6145.

Who recommended West Virginia University Hospitals to you?

__ Relative/acquaintance/friend

__ Insurance company

__ Embassy

__ Employer

__ Other, please specify:

Please check one:

__ Self-referral __ Physician referral

Referral request:

__ Second opinion __ Physician consultation __Hospital admission

Patient Information

Patient’s Name (Required):

Gender (Required): __ M __ F

Date of Birth (Month, Day, Year):

Permanent Address:

City:

State/Province:

Country:

Zip or Postal Code:

Home Telephone (Required):

Business Telephone:

Home E-mail:

Business E-mail:

Home Fax:

Business Fax:

Local Telephone (if available):

Local Fax (if available):

Emergency Contact Name:

Contact’s Telephone Number:

Religious preference:

Clinical Information

Patient Diagnosis:

Patient Clinical Status:

Clinical Department or Specialty:

Are medical records and test results available (MRI, CT scan, X-ray, etc.)?

Anticipated travel dates to United States:

From: to:

Who would accompany patient to the United States?

Referring Physician

Physician’s Name:

Affiliation:

Office Telephone Number:

Fax Number:

Emergency Telephone Number:

E-mail address:

Patient Services Information

Will you need assistance with the following?

• Interpreter Services:

__ Yes __ No

Languages you speak:

• Special diet: __ Yes __No

If yes, please specify diet:

If you have any questions, please contact Dawn Molnar, the International Program Coordinator

by telephone: 1-304-598-6144 or email: molnard@rcbhsc.wvu.edu.

Note: For self-pay patients requiring hospitalization, payment in advance is required.