Referral Form
Download our referral forms by county.
To refer a patient for imaging services, download and complete the referral form for the county where your practice is located. Completed forms can be faxed or emailed to our Provider Relations team.
Los Angeles County
For referring physicians with practices in Los Angeles County and surrounding areas. Serves UMIH locations in Beverly Hills, Century City, Downey, East Los Angeles, Gardena, Inglewood, Los Angeles, Maywood, and Torrance.
Orange County
For referring physicians with practices in Orange County and surrounding areas. Serves UMIH locations in Anaheim, Brea, Buena Park, Fountain Valley, Garden Grove, Huntington Beach, Irvine, Mission Viejo, and Santa Ana.
How to submit your referral
- Download form. Select the appropriate county form above.
- Complete information. Fill out all required patient and clinical information.
- Submit form. Fax or email the completed form to our office.
- Receive confirmation. We'll contact you within 24 hours to confirm.
Required information
- Patient: full name, date of birth, contact phone, insurance information, medical record number (if available).
- Clinical: reason for exam, ICD-10 diagnosis codes, relevant medical history, previous imaging.
- Study: type of study, body part, with/without contrast, urgency (routine, urgent, stat).
- Physician: referring physician name, office contact, preferred report delivery, NPI number.
Provider Relations contact
Phone: (310) 943-8400 · Fax: (310) 923-9912