Patient Referrals

Make a Referral for Testing or to a Provider

Outpatient Specialist Appointments

• Contact the specialties for referrals and consults. View the Specialist Directory for a list of available specialties and information.
• For Physiatry, complete the Physiatry Referral Request Form (Form 31841)
• Specialist Referral and Map for Patient/Family (Form 31829, Rev 10/20)
  
  
• For outpatient wound consults, please call Pediatric Surgery at 865-546-2131.

Refer for Pediatric Surgery

• East Tennessee Pediatric Surgery Group Referral Request (Form 32869, Rev 4/21)

Refer for Outpatient Testing

• Refer for Outpatient Testing

Specialty Clinics

• Refer to a Specialty Clinic

Additional Support Services

• Home Health Care
  (865) 675-8181
• Rehabilitation Center
  (865) 690-8961
  • Rehab Referral Form
  • Motivating Mealtimes Physician Referral
  • Motivating Mealtimes Brochure
• Surgery Scheduling
  (865) 541-8128/541-8588 (OR)
• Orders/Pre-Registration
  Fax (865) 541-8289
• Pediatric Physician Referral
  (865) 541-8439
• Physician Services
  (865) 541-8415

Release of Information and Other Regional Practice Forms

• Privacy Notice (English Form 31644​, ​Spanish Form 31645)
• In Locos Parentis Consent and Affidavit (English Forms 31646 and 32179, Spanish Form 31649)
• Parent/Guardian’s Consent (English Form 31647)
• Adult Patient Consent (English Form 31648, Spanish Form 31666)
• Patient Information (English Form 31654, Spanish Form 31655)
• Authorization for Release of Information from Another Facility (English Form 30399)