Refer a Patient

For referrals to the Comprehensive Memory Center please complete print, complete, and fax the following forms to 1-512-495-5680:

• Counseling Referral Form (pdf)
• Patient Referral Form (pdf)
• UT Health Austin Authorization to Receive Records

For referrals to the Livestrong Cancer Institutes, please print, complete, and fax the following forms to 1-512-495-5709:

• UT Health Austin Referral Form
  
• UT Health Austin Authorization to Receive Records

The Post-COVID-19 Program at UTHA is currently accepting new referrals. We review all referrals prior to scheduling, so please review the recommendations below to ensure that patients can be scheduled without delay.

To Refer a Patient:

• Patients must be at least 12 weeks from their initial COVID-19 infection (research shows that most symptoms resolve within this window, but symptoms remaining at 12 weeks are likely to persist).
• Patients with any significant medical comorbidities must have a primary care provider and be engaged in treatment of those comorbidities. The Post-COVID-19 Program is a consultative service that works closely with primary care providers and other specialists to provide care.
• The most common symptoms of long COVID are fatigue, neurocognitive impairment, and post-exertional malaise. Many patients experience shortness of breath and palpitations that may be related to other neurologic symptoms and autonomic dysfunction or cardiopulmonary problems.

Prior to Referring a Patient:

• Please review the Multidisciplinary PASC Guidance Statements to obtain an initial workup based on your patient’s symptoms. This includes a basic workup to rule out alternative etiologies of the symptoms.
• Examples of testing to consider are basic labs, such as a CBC, CMP, TSH, ESR, CRP, and A1c. For cardiopulmonary symptoms, the Post-COVID-19 Program encourages testing, such as a baseline EKG, chest X-ray, or pulmonary function tests. An article about their approach to care can be found here.
• Please note that long COVID symptoms typically begin within 8 weeks of the initial COVID-19 illness, although the neurologic symptoms can have delayed onset of 4-8 weeks. If your patient had a full recovery, then developed unexplained symptoms months later, the Post-COVID-19 Program recommends providers comprehensively evaluate alternative etiologies prior to referral to the Post-COVID-19 Program.

When Referring a Patient:

• Please include when the patient’s COVID-19 infection or reinfections occurred, and which symptoms are likely attributable to long COVID and not another comorbidity. If the referral documentation does not include this information, we will likely send a letter to request more information prior to scheduling.
• The Post-COVID-19 Program encourages providers to share patient education resources with their patients prior to their initial appointment. These resources include patient education videos, an extensive FAQ on long COVID, handouts for self-management strategies, and more.

For referrals to the Post-COVID-19 Program, please print, complete, and fax the following forms to 1-512-495-5709:

• UT Health Austin Referral Form (or complete our secure online referral form)
  
• UT Health Austin Authorization to Receive Records

For referrals to the Surgical Oncology Clinic, please print, complete, and fax the following forms to 1-512-495-5709:

• UT Health Austin Referral Form
  
• UT Health Austin Authorization to Receive Records

For all other UT Health Austin referrals, please print, complete, and fax the following forms to 1-512-495-5680:

• UT Health Austin Referral Form (or complete our secure online referral form)
  
• UT Health Austin Authorization to Receive Records