Request Portal Access

New User Request Form
Referral Center Phone: 714-456-7001

New Users
Please fill this form and submit to UCI Referral Center for processing. It might take up to 2 days to get your username and password

Make sure to include,
- Provider Name and Address
- Provider Specialty

Provider Information

Provider Last Name

Provider First Name

Company Name

Provider Specialty

Provider NPI

Provider Office Phone

Address

Address Line 1

City

State

Zip

Office Contact

Last Name

First Name

Direct Number

Referral Portal

Provider Information

Address

Office Contact

Referral Center Online Portal