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 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?

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 AMISH AID 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 OF KANSAS Blue Cross Blue Shield OTHER PREFERRED CARE Blue Cross Blue Shield OTHER PREFERRED CARE BLUE 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 Cross Blue Shield SECONDARY Blue Cross Blue ShieldKS SOLUTIONS EXCHANGE INN Blue Cross Blue ShieldKS SOLUTIONS EXCHANGE Out of Network Blue Cross Blue ShieldKS SOLUTIONS INN Blue Cross Blue ShieldKS SOLUTIONS Out of Network BLUE SELECT EXCHANGE BLUE SELECT EXCHANGE INN BLUE SELECT INN CARE STATE OF KS CAREMARK 340B CARPENTERS MERITAIN PLAN CCO INC 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 COMMUNITY CARE NETWORK CONTACT LENS PROGRAM-SP ONLY CONTACTS SP 10 CONTACTS SP 15 CONTACTS SP 20 CONTACTS SP OTHER CORESOURCE TRUSTMARK COST SHARE SELF PAY COVENTRY COVENTRY NATIONAL CPAFE STATE OF MO DELUX FRAMES-SP ONLY 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 DO NOT BILL DO NOT DUNN EMPLOYEE DISCOUNT EMPLOYEE HEALTH EXPIRED PATIENT FACM ASSISTANCE 100% FACM ASSISTANCE 25% FACM ASSISTANCE 50% FACM ASSISTANCE 75% FINANCIAL ASSISTANCE 100% FINANCIAL ASSISTANCE COPAY FIRST HEALTH FIRST STEPS FMH BENEFITS FREEDOM NETWORK FREEDOM NETWORK HEALTHLINK FREEDOM NETWORK SELECT GEHA GLASSES AND FRAMES SP 10 GLASSES AND FRAMES SP 15 GLASSES AND FRAMES SP 20 GLASSES AND FRAMES SP OTHER GUARDIAN RESOURCES HEALTH PARTNERS OF KANSAS HEALTHLINK HealthPartners at UnityPoint Health Out of Network HealthSCOPE Benefits Out of Network HEARING AND SPEECH GRANT 100% HEARING AND SPEECH GRANT 50% HEARING AND SPEECH GRANT 60% HEARING AND SPEECH GRANT 70% HEARING AND SPEECH GRANT 80% HEARING AND SPEECH GRANT 90% HS FLO HARRIS GRANT 50% HS FLO HARRIS GRANT 60% HS FLO HARRIS GRANT 70% HS FLO HARRIS GRANT 80% HUMANA HUMANA EXCHANGE INTERNATIONAL PATIENT COMMERCIAL INSURANCE PLAN INTERNATIONAL PATIENT GOVERNMENT INSURANCE PLAN INTERNATIONAL PATIENT SELF PAY KS CRIME VICTIMS COMPENSATION KS MEDICAID KS MEDICAID AMERIGROUP KS MEDICAID PHYSICIAN SPONSOR KS MEDICAID PRESUMPTIVE ELIGIBILITY KS MEDICAID SUNFLOWER HEALTH PLAN KS MEDICAID UNITED HEALTHCARE KS MEDICAID UNITED PCN KS SPECIAL HEALTH CARE NEEDS MEDICA CONNECT EXCHANGE MEDICA SELECT MEDICA United Health Care Medicaid Out of State MEDICARE ADVANTAGE MEDICARE PART A MEDICARE PART B MEDPAY Mercy Anthem Alliance EPO Out of Network MERCY HEALTH PLANS MISC GOVERNMENT PROGRAMS MO CRIME VICTIMS COMPENSATION MO MEDICAID MO MEDICAID AETNA BH MO MEDICAID AETNA BH PCN MO MEDICAID HEALTHCARE USA MO MEDICAID HEALTHCARE USA PCN MO MEDICAID HOME STATE HEALTH PLAN MO MEDICAID MISSOURI CARE MO MEDICAID MISSOURI CARE PCN MO MEDICAID PRESUMPTIVE ELIGIBILITY MO MEDICAID UNITED COMM PCN MO MEDICAID UNITED COMMUNITY MO SPECIAL HEALTH CARE NEEDS MULTIPLAN OKLAHOMA MEDICAID OPTICAL VSP 10 OPTICAL VSP 15 OPTICAL VSP 20 OPTICAL VSP OTHER OPTUM *TRANSPLANTS* OTHER COMMERCIAL INSURANCE OTHER COMMERCIAL INSURANCE 4 OTHER COMMERCIAL INSURANCE SECONDARY PARALLEL PKWY CAP PHCS PHCS COST SHARE PLAN PRE-COLLECT BUDGET PRE-COLLECT DEFAULT Preferred CommunityChoice Out of Network PREFERRED HEALTH PROFESSNALS PREREGISTRATION ONLY QUIK TRIP PHCS SELF PAY SELF PAY PACKAGE PRICE SSI DISABILITY ST JOHN'S HEALTH PLAN SUPPLEMENTAL INSURANCE TITLE X (TEEN CLINIC ONLY) TRANSPLANT TRANSPLANT United Health Care OPTUM COMMERCIAL TRANSPLANT United Health Care OPTUM MEDICAID TRICARE UMR1 UNCLAIMED PROPERTY UNCLAIMED PROPERTY SELF PAY 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 VISION KS MEDICAID OCULAR BENEFITS VISION KS MEDICAID OPTICARE VISION MO MEDICAID MARCH VISION MO MEDICAID OPTICARE VISION VSP VISION VSP ACCESS VISION VSP ACCESS INDEMNITY WORK COMP WPPA PPO Other

Other

Policy #

Group #

Policy Holder Name

Policy Holder Date of Birth

Authorization #

Signature

*Printed Name (Provider)

I acknowledge the above represents my electronic signature.