AIRI is not an emergency service. For a medical emergency, call 911 or go to the nearest emergency department.

For referring clinicians

Outpatient Referral Form

Refer a clinic patient to the AIRI multidisciplinary intestinal rehabilitation program. Complete all applicable sections; incomplete forms may delay intake scheduling.

When you choose Email this referral, your own email program opens with the completed form in the message body — review it and send. Attach relevant records (operative reports, imaging, labs, nutrition and infusion orders) if your system allows, or send them by secure fax to (209) 290-3664. Referring a hospitalized patient instead? Use the inpatient referral form.

Before you send. Ordinary email is not a secure channel for protected health information. Send this form from a secure or encrypted email account, or use secure fax at (209) 290-3664. For an emergent situation, call (209) 313-4433 today — and for a medical emergency, call 911.

Referring provider

Provider name and credentials

Practice or facility

NPI number

Specialty

Phone

Fax

Date of referral

Patient demographics

Patient name

Date of birth

MRN, if known

Sex

Address

Phone

Preferred language

Emergency contact / caregiver

Relationship

Primary insurance

Primary policy / ID number

Secondary insurance

Secondary policy / ID number

Prior authorization obtained?

Primary care physician

Reason for referral

Other reason

Clinical history

Underlying diagnosis / etiology of intestinal failure

Remaining bowel anatomy (length, segments, ostomy or anastomosis)

Relevant surgical history (dates, procedures)

Current PN / IV fluid regimen (formula, volume, cycle, frequency)

Enteral / oral intake status

Vascular access type

Medications, allergies, and records

Current medications (including antimotility, antisecretory, GLP-2 analog, antibiotics)

Known allergies

Most recent labs attached or being sent

Imaging attached or being sent

CT or MRI abdomen Small bowel series Other

Services requested

Intestinal rehabilitation consultation Nutrition support / dietitian evaluation Home PN/IV management optimization GI motility / surgical evaluation Vascular access assessment Transplant center referral Psychosocial / care coordination support Telehealth follow-up enrollment

Urgency and scheduling

Urgency

Preferred visit type

Clinical notes / special considerations

Referring provider attestation

I attest that the information provided is accurate to the best of my knowledge and authorize release of relevant records to AIRI for care coordination purposes.

Provider name (typed signature)

Date

This form supports referral coordination and does not replace clinical evaluation or the prescribing responsibilities of the treating team. AIRI · 1148 W Hammer Ln, Stockton, CA 95209.