For Providers
Welcome! This page provides quick access to referral forms to help you connect patients with the care they need.
Referral Order Forms by Service
Referral forms are grouped by service type. Click on a service to expand the section and access relevant forms and guidelines.
Our services include nursing care, wound care, physical, occupational, and speech therapies. Available in Colorado, Idaho, Nevada, and Utah.
Our services include nursing care, Social Work, Chaplain, and volunteer services along with bereavement care. Available in Colorado, Idaho, Montana, and Utah.
Our equipment and supplies include mobility aids, wheelchairs, CPAPs, BiPAPs, compression stockings, incontinence supplies, and many more. Available in Montana and Utah.
Our services include IV infusions in the home such as antibiotics, hydration, TPN and specialty drugs like IVIG or chemotherapy. We also offer an array of Enteral formulas to meet every patient’s nutritional needs. We have an Ambulatory Infusion Suite in South Jordan for patients in the Greater Salt Lake area.
- IV order form (PDF)
- Hyperemesis order form (PDF)
- Intrauterine device order form (PDF)
- Send a fax to: 801-442-0709 with patients’ demographic information, prescription and updated H&P.
- Send an electronic prescription to: Intermountain Health Infusion Pharmacy (South Jordan or St. George, Utah).
- For general or specific questions, or to order infusion, parenteral or enteral services and supplies, please contact a pharmacist at 385-887-7353 or a dietitian at 385-887-6333.