For Physicians - UPMC Western Maryland

For Physicians

UPMC Western Maryland provides quick and easy access to referral forms and offers additional health care resources for all of our physicians.

Outpatient Diagnostic Order Forms and Referrals

This section of the UPMC Western Maryland website is reserved for physician practices and UPMC Western Maryland partners, for the purpose of providing downloadable copies of the order forms and referrals needed for Outpatient Diagnostic Services at UPMC Western Maryland.

Cardiology Order Form

Center for Clinical Resources (CCR) Referral Form, including Heart Failure Services, Sepsis, COPD, Medication Therapy

Diabetes Services Referral Form, including Diabetes Self-Management Training and Medical Nutrition Therapy

Outpatient Anticoagulation Clinic Referral Form

Outpatient Physical Therapy Services Form

Referral Form for Registered Dietitian (non-diabetes)

Diagnostic Imaging Order forms

General Radiology Order Form

Interventional Orders Forms

Lung Cancer Screening Order

Mammography Ordering Form

MRI Ordering Form

Nuclear Medicine Order Form

PET/ CT Order Form

Ultrasound Order Form

Physician Office Guide and Patient Instructions for CT Procedures

CT Scan Order Form

Laboratory Requisition Forms

Allergen Requisition

BB TYPEXMATCH Requisition for RBC

General Lab Requisition

Microbiology Requisition

Physician Order Form

Pre-Admission Testing Form

Prenatal OBGYN Form

New Wound and Hyperbaric Center Patient Form

Cepheid Fact Sheet for Providers

Liat Fact Sheet for Providers

Chronic Pain Management Resources

Resource List – Updated August 2018