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 Tic & Tourette Urology Weight Management

Reasons for Consultation --None--

Selected Specialty and Diagnosis

Specialty	Reasons for Consultation	Patient Symptoms	Action

*Preferred Appointment Timeframe--None--First Available (varies per clinic) < 3 Days (Call 800-GO-MERCY to request) 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

*Practice Name   (If your practice is not listed, type Unknown)

Clinic Not Found.

Provider

Provider Not Found.

Unknown Provider

*Name

*Credentials

*Office Phone   (Enter Back Office Phone Number if available)

*Office Fax

Office Contact

Primary Care Provider

Primary Care Provider same as Referring 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 # (Please note: If the patient has insurance, the policy number is required.)

Group #

Policy Holder Name

Policy Holder Date of Birth

Authorization #

Signature

*Printed Name (Provider)

I acknowledge the above represents my electronic signature.

For questions or concerns while using this form, email physicianservices@cmh.edu