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For consult requests requiring a patient to be seen in less than 3 days, please call 1-800-GO-MERCY (1-800-466-3729) and ask for an urgent appointment. For scheduling questions or questions regarding this form please call 816-234-3700.
Referral Information
Document Upload
STOP Please call 1-800 GO MERCY to discuss this patient with an on-call provider.
Please call 1-800 GO MERCY if patient is less than 10 years old to discuss with on-call provider.
Please attach growth charts for every referral. Please include lab and radiology results obtained within the last year. If you are unable to attach, please fax the documentation to 816-346-1384, to prevent any delays in patient care.
Stop Please have The parent call 816 234-3674 to schedule an appointment with this Specialty. The parent will be asked to fill out an electronic form regarding their childs request for services from Developmental and Behavioral.
STOP Please call 1-800 GO Mercy regarding this patient.
Please attach most recent labs, imaging related to referral and last clinic note with HandP if applicable.
STOP. Please have the referring doctor call 1-800-GO MERCY and request a consult with the Hematology/Oncology doctor on call.
Please fax over any records regarding the reason for referral to 816-855-1776. These records could include doctors notes, lab results or x ray results.
For amplified pain syndrome or fibromyalgia, please refer patient to Pain Management.
The Ophthalmology Clinic is not currently scheduling patients 10 years or older for routine exams unless they have a behavioral, developmental, or other complex medical issue that could make an eye exam more challenging
Please see the attached request for records and labs.
Click here to Open
Referral Information
Specialty
--None--
Adolescent Specialty
Allergy & Immunology
Burn unit
Cardiology
Comprehensive Colorectal Center
Dental
Dermatology
Developmental & Behavioral Sciences
Down Syndrome
Ear, Nose & Throat
Eating Disorders
Endocrine
Environmental Health
Fetal Health Center
Genetics
GI Feeding Clinic
GI General Clinic
GI Hepatology Clinic
GOLDILOKs
Gynecology
Hearing & Speech
Hematology & Oncology
Infectious Disease
Nephrology
Neurology
Neurophysiology Lab
Neurosurgery
Nutrition
Ophthalmology
Orthopaedic Surgery
Pain Management
Physical & Occupational Therapy
Plastic Surgery
Pulmonology
Rehabilitative Medicine
Rheumatology
Safety, Care & Nurturing(SCAN)
Sleep Medicine
Special Care
Sports Medicine
Surgery
Urology
Weight Management
Reasons for Consultation
--None--
Selected Specialty and Diagnosis
Specialty
Reasons for Consultation
Patient Symptoms
Action
*
Preferred Appointment Timeframe
--None--
First Available
Seven Days
Two Weeks
One Month
*
Preferred Appointment Location
--None--
Kansas City, MO
Independence, MO
Joplin, MO
North Kansas City, MO
Overland Park, KS
St. Joseph, MO
Telemedicine
Wichita, KS
Junction City, KS
KU Campus
Garden City
Great Bend
Olathe, KS
Telehealth Patient Home
Telemedicine Facilitated Wichita
Telemedicine Facilitated St. Joseph
Telemedicine Facilitated Joplin
Telemedicine Facilitated Junction City
Expectations for consultative Children’s Mercy (CM) provider (please choose one)
Provide the necessary care to evaluate and treat the specified condition and return to PCP/medical home for continuing care.
Provide long-term management of the specified condition with continued communication of the ongoing plan of care with the PCP/medical home.
Request for procedure only (ECHO > 4yrs, EKG, EEG)
Does the patient have any Syndromes (excluding Down syndrome) or any complex medical history?
--None--
Yes
No
Lab/Images Completed?
Lab/Images Location
Weight Management
*
Does the patient have a special healthcare need such as Autism Spectrum Disorder, Down Syndrome,physical or developmental disability?
--None--
Yes
No
*
Have you discussed bariatric surgery to help with weight loss for this patient?
--None--
Yes
No
*
What is the child’s current BMI percentile?
*
Can the child participate in regular education classroom as required?
--None--
Yes
No
Referring Provider
*
Clinic
Clinic Not Found.
Provider
Provider Not Found.
Unknown Provider
*
Name
*
Credentials
*
Office Phone
*
Office Fax
Office Contact
Primary Care Provider same as Referring Provider
Primary Care Provider
Name
Credentials
Patient Information
*
First Name
*
Last Name
*
Date of Birth
*
Gender
--None--
Female
Male
Unknown
Indeterminate
Unspecified
Height (In Inches)
Weight (In Lbs)
*
Preferred Phone
Parent/Guardian Information
*
First Name
*
Last Name
*
Relationship
--None--
Guardian
Mother
Father
Preferred Language
--None--
Amharic
Arabic
Bajuni
Bengali
Bosnian
Bulgarian
Bunjabi
Burmese
Cambodian
Cantonese
Chin
Chinese
Chuukese
Cronk/Liberian
Dinka
English
Ethiopian
Falam Chin
Farsi
Filipino
French
German
Haitian Creole
Hakha Chin
Hmong
Indonesian
Japanese
Karen
Kirin
Korean
Kurdish
Lautu Chin
Liberian
Loatian
Madi
Mai Mai
Mandarin
Micronesian
Mongolian
Nigerian Pigin
Nuer
Other
Persian
Pigin English
Portugese
Punjabi
Respondent N/A
Romanian
Russian
Samoan
Serbian
Serbo-Croatian
Sign Language
Somali
Spanish
Sudanese
Swahili
Tagalog
Ukranian
Urdu
Vietnamese
*
Primary Address
*
City
*
State
--None--
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip
Preferred Email Address
Insurance Information
*
Primary Insurance
--None--
AETNA
AETNA BENEFIT PLANNERS
AETNA HCA SMART CARE
AETNA MAIL HANDLERS BENEFITS
AETNA SRC
AETNA WAUSAU BENEFITS
ALL SAVERS
AMBETTER FOR HOME STATE HEALTH PLAN Out of Network
AMBETTER FOR SUNFLOWER HEALTH PLAN Out of Network
AMERICAN HEALTHCARE ALLIANCE
AMERICAN MEDICAL SECURITY LEGACY
ARKANSAS MEDICAID
BEECHSTREET
BEECHSTREET CERNER
BEHAVIORAL CIGNA
BEHAVIORAL CORPHEALTH INC
BEHAVIORAL HEALTH OTHER
BEHAVIORAL INTERFACE EAP
BEHAVIORAL KS MEDICAID CENPATICO
BEHAVIORAL KS MEDICAID UBH
BEHAVIORAL MHNET COVENTRY
BEHAVIORAL MO MEDICAID CENPATICO
BEHAVIORAL MO MEDICAID MHNET
BEHAVIORAL MO MEDICAID UBH
BEHAVIORAL NEW DIRECTIONS
BEHAVIORAL OPTUM
BEHAVIORAL VALUE OPTIONS
BLUE CARE HMO
BLUE CHOICE HMO
Blue Cross Blue Shield BLUE ACCESS Out of Network
Blue Cross Blue Shield BLUE SELECT Out of Network
Blue Cross Blue Shield Federal Employee Program
Blue Cross Blue Shield Kansas Solutions Exchange
Blue Cross Blue Shield of Kansas
Blue Cross Blue Shield OTHER PREFERRED CARE
Blue Cross Blue Shield Pathway/Pathway X Out of Network
Blue Cross Blue Shield PREF CARE BLUE EXCHANGE
Blue Cross Blue Shield PREFERRED CARE BLUE
BLUE SELECT Blue Select Plus
CAREMARK 340B
CARPENTERS MERITAIN PLAN
CENTURY HEALTH SOLUTIONS
CERNER HEALTH PLAN SERVICES FREEDOM NETWORK
CHAMPVA
CHRISTIAN HEALTH AID
CIGNA
CIGNA CMH EMPLOYEE PLAN
CIGNA CONNECT EXCHANGE
CIGNA GREAT WEST
CIGNA HEALTH PARTNERS
Cigna Health Partners Unity Point Out of Network
COMMUNITY CARE NETWORK
CONTACT LENS PROGRAM-SP ONLY
CORESOURCE TRUSTMARK
COST SHARE SELF PAY
COVENTRY
COVENTRY NATIONAL
DENTAL DELTA DENTAL
DENTAL INSURANCE
DENTAL INSURANCE SECONDARY
DENTAL KS MEDICAID DHW
DENTAL KS MEDICAID SCION
DENTAL METLIFE DENTAL
DENTAL MO MEDICAID
DENTAL MO MEDICAID DENTAQUEST
DENTAL MO MEDICAID DHW
DENTAL MO UNITED COMMUNITY PLAN
DENTAL PREFERRED CARE
DENTAL TRICARE
FIRST HEALTH
FIRST STEPS
FMH BENEFITS
FREEDOM NETWORK
FREEDOM NETWORK HEALTHLINK
FREEDOM NETWORK SELECT
GEHA
Health Choice Oklahoma-Out of Network
HEALTH PARTNERS OF KANSAS
HEALTHLINK
HealthPartners at UnityPoint Health- Out of Network
HealthSCOPE Benefits Out of Network
Healthscope Mercy Arkansas
HUMANA
HUMANA EXCHANGE
INTERNATIONAL PATIENT COMMERCIAL INSURANCE PLAN
INTERNATIONAL PATIENT GOVERNMENT INSURANCE PLAN
INTERNATIONAL PATIENT SELF PAY
Kaiser Permanente Southern CA Out of Network
KS MEDICAID
KS MEDICAID AETNA BETTER HEALTH
KS MEDICAID AETNA BETTER HEALTH PCN
KS MEDICAID SUNFLOWER HEALTH PLAN
KS MEDICAID UNITED HEALTHCARE COMMUNITY PLAN
KS MEDICAID UNITED HEALTHCARE COMMUNITY PLAN PCN
KS SPECIAL HEALTH CARE NEEDS
MEDICA CONNECT EXCHANGE
MEDICA SELECT
MEDICA United Health Care
Medicaid Colorado Out of Network
Medicaid Illinois Out of Network
Medicaid Iowa Out of Network
Medicaid Out of State Out of Network
Medicaid Texas Out of Network
MEDICARE ADVANTAGE
MEDICARE PART A
MEDICARE PART B
MEDPAY
Mercy Anthem Alliance EPO (Anthem BCBS) -Out of Network
MERCY HEALTH PLANS
MO MEDICAID
MO MEDICAID Healthy Blue
MO MEDICAID Healthy Blue PCN
MO MEDICAID HOME STATE HEALTH PLAN
MO MEDICAID UNITED COMMUNITY PLAN
MO MEDICAID UNITED COMMUNITY PLAN PCN
MO SPECIAL HEALTH CARE NEEDS
MULTIPLAN
OKLAHOMA MEDICAID (Referral Required)
Oscar Health Out of Network
OTHER COMMERCIAL INSURANCE
PHCS
PHCS COST SHARE PLAN
PHCS Practitioners Only - Out of Network
Preferred CommunityChoice Out of Network
PREFERRED HEALTH PROFESSNALS
QUIK TRIP PHCS
SELF PAY/NO INSURANCE
ST JOHN'S HEALTH PLAN
TRICARE (Referral Needed)
UMR1
United Health Care CHOICE PLUS DEFINITY
United Health Care GOLDEN RULE
United Health Care NAVIGATE
UNITED HEALTHCARE
UNITED HEALTHCARE CHOICE
USA MANAGED CARE ORG
VISION KS MEDICAID MARCH VISION- OUT OF NETWORK
VISION KS MEDICAID OPTICARE/ENVOLVE VISION
VISION KS MEDICAID SKYGEN USA
VISION MO MEDICAID MARCH VISION Out of Network
VISION MO MEDICAID OPTICARE/ENVOLVE VISION
VISION VSP
VISION VSP ACCESS
VISION VSP ACCESS INDEMNITY
WPPA PPO
WPPA ProviDRs Care Employer Network Design- City of Pittsburg Out of Network
Other
Other
***Please note, your patient has an insurance plan that does not participate with Children’s Mercy and is out of network. Without pre-approval to be seen at an out of network facility, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for
"What if I have an Out of Network Plan"
to avoid scheduling delays and reduce surprise financial costs to the family.
***Please note, your patient has an insurance plan that requires an approved referral from Oklahoma Medicaid in order to be seen outside of the state of Oklahoma. Without a pre-approved referral, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for to obtain a referral from Oklahoma Medicaid and enter the referral number below.
***Please note, your patient has an insurance plan that does not cover any services performed in an outpatient hospital setting. This specific plan will only cover office visits with an physican or nurse practitioner. Without pre-approval to have services outside of an office visit, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for
"What if I have an Out of Network Plan"
to avoid scheduling delays and reduce surprise financial costs to the family.
***Please note, by selecting "Self Pay/No Insurance" you are indicating the patient will be paying out of pocket for services. Patients who do not have active insurance need to speak to a Children’s Mercy Financial Counselor prior to their appointment to get help covering the costs of care. To avoid your patient experiencing scheduling delays or higher out of pocket balances, please refer your patient to contact Financial Counseling
here
***Please note, your patient has an insurance plan that may require an approved referral from the patient's primary care provider/manager. Some Tricare plans require a referral in order to be seen with a specialist that is not located at military treatment facility. Without a pre-approved referral, your patient may experience scheduling delays or higher out of pocket balances. If required, please ensure you and your patient have followed the steps for to obtain a referral on the Tricare website and enter the referral number below.
***Please note, your patient has an insurance plan that does not cover any services performed in an outpatient hospital setting. (Examples: Labs, Imaging, Procedures, Medications, or any services outside of professional charges for an office visit would not be covered.) This specific plan will only cover an office visit with an physican or nurse practitioner at Children's Mercy. Without pre-approval, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for
"What if I have an Out of Network Plan"
to avoid scheduling delays and reduce surprise financial costs to the family.
Policy #
Group #
Policy Holder Name
Policy Holder Date of Birth
Authorization #
Signature
*
Printed Name (Provider)
I acknowledge the above represents my electronic signature.