Developmental Behavioral Pediatrics Referral Form - UK HealthCare 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name and date of birth accurately to ensure proper identification.
3. Next, complete the 'Parent/Guardian Information' section. Provide the name, relationship to the patient, and contact details for effective communication.
4. In the 'Patient Insurance' section, include the insurance provider's name, group number, member ID number, and details of the primary insured party.
5. Fill out the 'Medical Provider Referral Information' with details about the referring physician or practice. Ensure all contact information is correct for seamless follow-up.
6. For the 'Reason For Referral', check all applicable boxes that describe the patient's concerns. This helps prioritize referrals based on urgency.
7. Finally, review all entered information for accuracy before submitting. Once completed, fax this form along with any supporting documents to 859-218-7487.

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