For referring clinicians
Refer a patient
Use this page to refer hospitalized or outpatient patients who require parenteral nutrition, have intestinal failure, or may benefit from AIRI consultation and transition planning.
Three ways to refer
Phone
Best for imminent discharge, an active TPN transition concern, or a quick question about fit.
Secure fax
(209) 290-3664
Best for a complete referral packet with records attached. Preferred route for protected health information.
Referral form below
Fills in an email from your own account, addressed to the AIRI referral coordinator. Send records separately by secure fax.
Referral criteria
Referrals are appropriate for adults diagnosed with intestinal failure — or at high risk for recurrent intestinal failure — including those who depend on parenteral nutrition for 60–90 days or longer, and for transition-age patients aged roughly 16–25 leaving pediatric intestinal rehabilitation programs. See the full list of conditions treated.
Clinical red flags that should prompt a referral
- Anticipated or actual parenteral nutrition use beyond hospitalization
- Recurrent unplanned hospitalizations for dehydration, electrolyte abnormalities, or line sepsis
- Difficulty advancing enteral or oral intake despite optimal local management
- Persistent high-output stoma or fistula affecting hydration and nutrition
- Progressive weight loss, sarcopenia, or failure to thrive in the setting of intestinal disease
- Evidence of or concern for intestinal failure–associated liver disease
Records to send with the referral
Sending these at the time of referral avoids a round of follow-up requests.
- Face sheet and insurance information
- Recent clinic notes and hospital discharge summaries related to GI or intestinal-failure care
- Operative reports and pathology reports for any bowel resection
- Current PN/TPN order and prior formulations, with infusion schedule
- Most recent seven days of relevant laboratory results, including CBC, CMP, liver enzymes, INR, and micronutrients when available
- Current medication administration record and medication list
- Nutrition and pharmacy notes
- Imaging and endoscopy reports relevant to bowel anatomy, obstruction, fistula, or vascular access
- Central-line procedure notes and infection or thrombosis history
- Case management, discharge planning, and home-infusion documentation
- Weight history covering 6–12 months, when available
Inpatient intestinal failure referral form
Referring a clinic patient instead? This form is for hospitalized patients. For clinic-to-clinic referrals, use the outpatient referral form.
Fill in what you have. Blank fields are left out of the email. When you choose Email this referral, your own email program opens with the completed form in the message body — review it, attach records if your system allows, and send.
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. If neither is available, send the clinical detail by fax and use the form only to reach the coordinator.
This form supports referral coordination. It does not replace inpatient medical evaluation, hospital nutrition-support protocols, emergency care, or the prescribing responsibilities of the treating clinical team.