Neurosurgery Referral Form

Prior to completing the form below, please click here to review our Neurosurgeons by area of specialty and requirements for each.

Our physicians see patients at The Kirklin Clinic of UAB Hospital, 2000 6th Avenue South – 2nd Floor Birmingham, AL , Medical West, 995 9th Ave SW, Prof Office Bldg Suite 103, Bessemer, AL (Dr. Renee Chambers ONLY), and UAB Greystone, 7500 Hugh Daniel Dr., Suite 200, Birmingham, AL 35242 (Dr. Staner ONLY)

All new patient referral packets require a copy of the patient’s insurance card and photo ID.

UAB Neurosurgeon Requested

Prior to selecting a surgeon below, please review the PDF linked above.

DIAGNOSIS/Reason for referral (NOT CODES)(Required)

Patient's Full Name(Required)

First Middle Last

Gender

Date of Birth(Required)

Social Security Number

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Phone Number(Required)

Work Phone Number

Cell Phone Number

Email Address

Insurance Information

Insurance 1st

Group #

Contract #

Insurance 2nd

Group #

Contract #

Referring Physician(Required)

First Last Suffix

NPI

Please enter a number greater than or equal to 10.

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Number(Required)

Fax Number(Required)

Office Contact

First Last

Is this a Workers' Compensation injury?(Required)

Yes

Workers' Compensation Providing Company Information (if applicable)

Contact Name

First Last

Telephone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Case/Approval Number(Required)

Date of Injury(Required)

Hidden

Section Break

Please fax all records to 205-934-6507.

Records(Required)

Checking this box confirms records and clinic notes have been faxed to (205) 934-6507. Please submit recent imaging via PACS, Ambra or mail to: UAB Neurosurgery, Neuroscience One, 2000 6th Ave. South, Birmingham, AL, 35233.