Required Information

Please fax the following information to 916-703-5627.

  • 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
  • Required authorization for all CPT Codes
    • Consult 99245 x 1
    • Follow Up 99214 x 4
    • Cystoscopy 52000 x 1
    • Urodynamics 51726-51729,51784,51797 x 1
    • Uroflow 51741 x 5
    • Pessary Fitting 57160 x 2
    • Bladder Scan 51798 x 5

 

Contact Information:

Randa Sultana-LittleField (Referral/Authorization Coordinator)
Department of Obstetrics and Gynecology
UC Davis Health System
4860 Y Street Suite 2500
Sacramento, CA 95817
Phone: 916-734-4129
Fax: 916-703-5627