Center for Surgical Health Referral Form

Thank you for referring your patient to the Center for Surgical Health. Please enter all required information. We will review the patient's clinical eligibility within one week. If eligible, we'll contact the patient for intake. If ineligible or in need of more clinical information, we will reach out to you.

The Center for Surgical Health is a surgical support program. CSH helps to connect patients with an unaddressed, non-acute surgical diagnosis to attending surgeons at Penn Medicine. We provide navigation, education, and empowerment services, support with access to financial coverage and high-quality surgical care, and referrals to additional social services.

For more information, please visit our website at www.centerforsurgicalhealth.org. For questions, please send us an email at csh@pennmedicine.upenn.edu or call us at 267-702-5530.

Referring Provider Information

Referring Provider Name

Referring Provider Email

Referring Provider Phone Number

Referral Location Source

Referral Location Source Somewhere Else

I understand that the Center for Surgical Health needs my partnership to help this patient access surgical care and that CSH may contact me for more information about this patient. I agree to respond promptly to requests for additional patient information from the CSH team.

I agree.

This patient has been informed that they are being referred to the Center for Surgical Health. They understand that they have a potential surgical condition which may need additional assessment.

YesNo

Patient Information

Patient's Legal First Name

Patient's Legal Middle Name

Patient's Legal Last Name

Chosen Name

Pronouns

PennChart MRN (N/A if unknown)

Referral Source MRN

Date of Birth (MM/DD/YYYY)

Gender Identity

Sex Assigned at Birth

Patient Phone Number

Patient Email Address

Alternate Contact Name (first and last)

Alternate Contact Relationship to Patient

Alternate Contact Phone

Alternate Contact email

Patient Primary Language

Primary Language Something Else

Medical Information

Surgical Diagnosis

Reason for Referral
(Ctrl + Click to select multiple)

Referral Notes

How will CSH access this patient's relevant medical records?

Relevant records are attached.Records will be emailed or faxed.CSH has EMR access (PennChart or Puentes OneTouch).

PLEASE NOTE:
To send records directly to CSH please email csh@pennmedicine.upenn.edu or fax 215-240-6322. Please include all relevant encounter notes, labs, and imaging within one business day of submitting this referral.

Patient Files (Add up to 10. If you have more than 10 files, please contact us.)

Encounter notes, imaging, and lab results