PATIENT INFORMATIONPatient’s Name: ______________________________________q M q F DOB: __________________________________Parent/Guardian Name(s): ______________________________
Home Phone: _________________________________________
Cell Phone:_________________Work Phone _______________
Email address: ________________________________________
Preferred Contact Phone: q Work q Cell q Home
Do you need an interpreter? _____________________________
Patient is in custody of: q Parents q Guardian q CSB Address: ____________________________________________
City:__________________State___________Zip ____________
1st Insurance:__________________ID# ____________________
Precert # __________________________________________
2nd Insurance:__________________ID# ____________________
Precert # __________________________________________
REASON FOR REQUEST Diagnosis Code/Reason for request: __________________________________________________________________________________
Additional relevant diagnostic/clinical information or testing: ________________________________________________________________
Please list any additional mental or physical disabilities: ___________________________________________________________________
Please check: q Diagnose only q Diagnose and treat
Additional clinical documentation is included with this request: q Yes q No (PLEASE include ALL applicable clinical documentation to assist in triaging appointments.)
SERVICES REQUESTED
REQUESTING PROVIDER GROUP:Office name __________________________________________Provider name ________________________________________Office location _________________________________________Office contact person____________________________________Phone ______________________Fax______________________Signature _____________________________________________
Date of Request: ______________________________PLEASE PRINT (ALL INFORMATION IS REQUIRED)
Our goal is to process referrals within two business days. If unable to contact family within one week,
we will notify your office.
**If it is medically necessary for this patient to be seen urgently by a physician,
call the department directly. **
Central Scheduling/Specialty Clinic Notes:
❏ Adolescent Young Adult Medicine Clinic
❏ Airway Clinic❏ Allergy/Immunology Clinic❏ Autism Clinic❏ Burn/Wound Clinic❏ Cardiology Clinic❏ Preventative Cardiology Clinic❏ CARE Clinic❏ Cerebral Palsy Clinic ❏ Children’s Health Clinic❏ Cleft Lip/Cleft Palate❏ Dentistry and Oral Surgery
❏ Developmental Pediatrics Clinic❏ Diabetes Clinic❏ Down Syndrome Clinic❏ Endocrinology Clinic❏ ENT Clinic❏ ENT Advanced Pediatric/ Airway Clinic❏
Gastroenterology Clinic
❏ Genetics Clinic❏ Genetic Counseling Clinic❏ Gynecology Clinic❏ Hematology/Oncology Clinic
❏ HighRisk Infant Nutrition Clinic❏ Immunology Clinic❏ Infectious Disease Clinic❏ Lead Poisioning Clinic❏ Lipid Clinic❏ Liver Clinic ❏ Myelomeningocele Clinic❏ Nephrology/Hypertension Clinic❏ Neurology Clinic❏ Neurosurgery Clinic❏ Nutrition Clinic❏ Opthalmology Clinic
❏ Orthopaedics Clinic❏ Pain Clinic❏ Physical Medicine and Rehabilitation Clinic❏
Plastic Surgery Clinic❏ Psychiatry Clinic❏ Psychology Clinic❏ Pulmonary Clinic ❏ Sleep Clinic❏ Sports Medicine Clinic❏ Surgery/Pediatric Clinic❏ Urology Clinic
❏ Routine 㭸 㭸 ❏ Urgent
RFSS_166214_8/17
REFERRAL FOR SPECIALTY SERVICES Central Scheduling
PH: 937-641-4000 Fax: 937-641-4500 Toll Free Fax: 866-891-6941One Children’s Plaza • Dayton, OH 45404-1815 • childrensdayton.org
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