Required Information

Please fax the following information to (916)734-6034.

MFM Referral Form

  • PT Records
  • PT Demographic Information
  • PT Insurance Information (Subscriber Info, ID #, Customer Service Plan)
  • Referring MD Information
  • Referral Coordinator Contact Information with Direct/Back Line Phone Number
  • Please call for required CPT Codes that need to be authorized.

 

Contact Information:

Sherri Gager-Hancock (Referral/Authorization Coordinator)
Department of Obstetrics and Gynecology
UC Davis Health System
4860 Y Street Suite 2500
Sacramento, CA 95817
Phone: 916-734-8068
Fax: 916-734-6110