Thank You

Home/Thank You

Thank YouUHSDEV2019-02-07T09:38:46-08:00

Thank You

View Price Guide >

Physicians are on the medical staff of Heritage Oaks Hospital, but, with limited exceptions, are independent practitioners who are not employees or agents of Heritage Oaks Hospital. The facility shall not be liable for actions or treatments provided by physicians. Model representations of real patients are shown. Actual patients cannot be divulged due to HIPAA regulations. TRICARE® is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

HIPAA Notice
Nondiscrimination Notice
Standard Services
Language Assistance
Privacy Policy
Sitemap
Download Adobe Acrobat Reader

To make a referral, please complete the items below and click “Submit” to send this confidential form to an Assessment and Referral clinician.

You can also fax it to 1-800-217-6218

Patient Name*
First Last
Patient Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Date Format: MM slash DD slash YYYY
Insurance Carrier*
Referred By*
Referral Contact Phone Number*
Diagnosis/Symptoms to be treated/Reason for referring:*
Comments
This field is for validation purposes and should be left unchanged.

This form is monitored during regular business hours only.

For immediate assistance, please call our Assessment and Referral line directly at 916-830-2223.

Download Form

Generic selectors

Exact matches only

Search in title

Search in content

Search in excerpt

Search in posts

Search in pages