Fillable REQUEST FOR A SPECIALTY CLINIC APPOINTMENT

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REQUEST FOR A SPECIALTY CLINIC APPOINTMENT

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REQUEST FOR A SPECIALTY CLINIC APPOINTMENT
Specialty__________________________________
MD _________________________________________
Specialty Phone____________________________
Specialty FAX_______________________________
For Specialty Office Use
Date Received_________________________________
Appointment Date/Time_______________________
Appointment Location__________________________
PATIENT NAME _______________________________________________________________________________________________________________________________
Last First Middle Initial Preferred Name to go by
LIST ANY NAME (OTHER THAN THE NAME PRINTED ABOVE) THAT THE PATIENT GOES BY________________________________________________________________________
Last First Middle Initial
HAS THE PATIENT EVER VISITED ANY OF THE LOCATIONS BELOW? (CHECK ALL THAT APPLY.)
Children’s ER
p Children’s South p Children’s Lakeshore p Children’s on 3rd p
DOB__________________AGE______SEX_______RACE__________________SOCIAL SECURITY NUMBER____________________________________________________
ADDRESS ____________________________________________________________________________________________________________________________________
Street City State Zip
PHONE _______________________________________|_______________________________________|_______________________________________________________
Check preferred Home p Work p Cell p
Contact Number
PARENT/GUARDIAN___________________________________________________DOB_________________EMAIL______________________________________________
_______________________________________________________________________________________________________________
PERSON RESPONSIBLE FOR BILL/GUARANTOR RELATIONSHIP TO PATIENT DOB
_________________________________________________________________________________________________________________
PRIMARY INSURANCE COMPANY
_________________________________________________________________________________________________________________
PRIMARY POLICY NUMBER GROUP NUMBER
_________________________________________________________________________________________________________________
CARD HOLDER'S NAME DOB ADDRESS (if different from above)
_________________________________________________________________________________________________________________
SECONDARY INSURANCE COMPANY (if applicable)
_________________________________________________________________________________________________________________
SECONDARY POLICY NUMBER GROUP NUMBER
_________________________________________________________________________________________________________________
CARD HOLDER'S NAME DOB ADDRESS (if different from above)
REASON FOR REFERRAL? ______________________________________________________________________________________________
WHAT IS YOUR SPECIFIC QUESTION FOR THE SPECIALIST?
______________________________________________________________________________________________________________
IS THIS IS A SECOND OPINION? YES p NO p IF SO, WHAT IS THE NAME OF THE PREVIOUS PROVIDER/CLINIC AND WHEN WAS THE PATIENT LAST SEEN?
_______________________________________________________________________________________________________________
DATE OF INJURY __________________________________________________________ MOTOR VEHICLE p OTHER p
________________________________________________________________________________________________________________
NAME DOCTOR'S UPIN NUMBER INDIVIDUAL NPI NUMBER
__________________________________|______________________________________________________________________________
PHONE NUMBER FAX NUMBER PCP (if different from above)
_________________________________________________________________________________________________________________
REFERRAL NUMBER CONTACT PERSON/EXTENSION
INTERPRETER NEEDED? YES p NO p LANGUAGE/HEARING/OTHER REQUESTED
_________________________________________________________________________________________________________________
ALLERGIES? YES p NO p If yes, please list.
NAME DOSAGE FREQUENCY
___________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
CURRENT MEDICATIONS / HERBAL PRODUCTS / NUTRITIONAL SUPPLEMENTS
Medication Reconciliation Form or copy of assessment in chart may be attached.
ADDITIONAL INFORMATION
REFERRING PHYSICIAN INFORMATION
DIAGNOSIS
INSURANCE INFORMATION If patient has Medicaid, please also fax/send Medicaid Referral Form (EPSDT Screening).
PATIENT DEMOGRAPHICS Demographic sheet may be attached.
Revised
08/24/21
Specialty: Select from drop down
RESET FORM
SAVE AS PDF
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*Relevant: All documentation related to the specific diagnosis for which the patient is being referred.
Children’s of Alabama Patient Registration Phone: 205.638.9141 or 800.226.4770.
Revised
8/23/21
Cardiology 205.975.6291 Please fax referral and all relevant records to 205.975.6291. 205.934.3460
Administrative Assistants will call the family to schedule an
appointment and will fax a copy of the appointment letter
to the referring physician’s office.
Children's Behavioral Health 205.638.9949 All appointments are made by phone and are scheduled 205.638.9193
by patient’s legal guardian. Legal guardian must call
for an appointment.
Dental 205.638.9796 205.638.9161
or 205.638.9141
Dermatology 205.638.2851 Fax all relevant* records and labs to 205.638.2851. NEW PT 205.638.5759
FOL/UP 205.638.9141
Endocrinology/Diabetes 205.638.9821 Fax growth charts, all relevant* records, labs, current 205.638.9107
demographic information. Option 2
ENT 205.638.4983 Fax all relevant* records, labs and imaging prior to 205.638.4949
(Pediatric ENT Associates) appointment marked ATTN: Appointment date and time. Option 2
Gastroenterology 205.638.9919 Fax this completed form along with insurance referral (if NEW PT 205.638.5457
needed) and all relevant records (i.e., current growth chart, FOL/UP 205.638.9141
clinic notes, labs, pathology, imaging & endoscopy reports).
Genetics 205.975.6389 Fax patient demographic and insurance information, insurance 205.934.4983
referral, if needed, reason for the referral, last 2-3 clinic notes, labs.
Hematology/Oncology 205.975.1941 Fax all relevant* records, labs and imaging; 205.638.9285
ATTN: Julie Brodie
Infectious Disease 205.975.6549 Fax all relevant* records, labs, growth chart, immunization records 205.934.2441
and demographic information.
Nephrology 205.975.7051 Fax all relevant* records, labs, ultrasounds, VCUGs. 205.638.9781
Send all study films to the appointment with patient.
Neurology 205.638.2602 Fax all relevant* records, labs, MRIs, CTs and EEGs. 205.638.2551
Send relevant* imaging to the appointment with patient.
Neurology 205.638.5879 Fax all relevant* records, labs, MRIs, CTs and EEGs. 205.638.5881
(Children’s South) Send relevant* imaging to the appointment with patient. or 205.638.5880
Neurosurgery 205.638.9972 Fax this form completed, insurance referral, clinical note, 205.638.9653
imaging reports, ALL growth charts (3 and under).
Parents MUST bring outside imaging CD to appointment.
Oral Maxillofacial Surgery 205.987.5034 Fax all relevant records; email all x-rays to kmmcbride@uabmc.edu 205.987.1173
Orthopedics 205.638.3699 Send x-ray, CT, MRI films with patient to appointment. 205.638.3373
Plastic Surgery 205.638.5340 Appointment email address: plastic.appointments@ChildrensAL.org 205.638.9369
Send x-ray, CT, MRI films with patient to appointment.
Pulmonary Medicine 205.638.2850 Fax this form with correct patient insurance information 205.638.9583
and referral to ATTN: Pulmonary Scheduler. Option 1
Rehab Medicine 205.638.9793 Fax insurance referral, clinic note from referral source 205.638.9790
and all relevant records. Option 1
Rheumatology 205.638.2875 Fax all relevant* lab, imaging results and records. 205.638.9438
Please include appointment date and time.
Sleep Medicine 205.638.2466 Please attach patient history. 205.638.9386
Sports Medicine 205.975.6109 Fax all relevant* information, including demographic and insurance 205.934.1041
information. Send x-ray or MRI films to the appointment
with the patient.
Surgery (General) 205.975.4972 Fax referrals and all relevant* records, labs, MRIs and CTs. 205.638.9688
Urology 205.975.6024 Fax all relevant* records and labs. Send x-ray, CT, MRI 205.638.9840
films with patient to appointment.
Weight Management 205.212.2735 Fax all relevant* records (insurance referral, if needed; lab 205.638.5750
work within last 6 months), growth chart and clinic notes.
Please indicate if patient is being referred for LESTER®
(ages 6-11), Healthier Weigh ®(ages 12-18) or bariatric surgery.
SPECIALTY FAX HOW TO SCHEDULE APPOINTMENT PHONE
Adolescent Health Center 205.638.2071 Fax this completed form with an insurance referral (if needed), 205.638.9231
(ADHD, Eating D/O, LEAH, growth chart, any labs within the last 6 months, and clinic notes
LARC, Menstrual D/O, for the last year.
Nutrition & Primary Care)
Aerodigestive Program 205.638.2075 Fax/submit special Aerodigestive referral form. Please submit 205.638.3447
clinic notes, imaging, growth curve, labs, pathology.
Allergy/Immunology 205.638.2833 Fax all relevant* records, labs and immunization records. 205.638.6993
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REQUEST FOR A SPECIALTY CLINIC APPOINTMENT

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Completed 30 March 2022

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