Refer a Pediatric Patient to the Outpatient Specialty Centers

2801 Atlantic Ave.
Long Beach, CA 90806

NOTE: This form is only to be used by a referring provider office.

PATIENT'S INFORMATION

PATIENT'S NAME (LAST, FIRST, MIDDLE)

GUARDIAN'S NAME (LAST, FIRST, MIDDLE)

BEST CONTACT PHONE NUMBER

IS THIS AN EMERGENT OR FETAL REFERRAL? IF SO, PLEASE INDICATE IT BELOW.
ALL EMERGENT OR FETAL REFERRALS TO BE REVIEWED BY AN RN AND TRIAGED APPROPRIATELY.

EMERGENT/FETAL NON-EMERGENT

REFERRING PROVIDER'S INFORMATION

REFERRING PROVIDER'S NAME (LAST, FIRST, MIDDLE)

REFERRING PROVIDER'S PHONE NUMBER

REFERRING PROVIDER EMAIL ADDRESS FOR CORRESPONDENCE

REFERRING PROVIDER'S ADDRESS

CITY

STATE

ZIP CODE

REFERRING PROVIDER'S OFFICE CONTACT (LAST, FIRST, MIDDLE)

REFERRING PROVIDER'S OFFICE CONTACT PHONE NUMBER

WHAT SPECIALTY ARE YOU REFERRING TO?

PRIMARY CHIEF COMPLAINT

PRIMARY DIAGNOSIS CODE (ICD-10)

PREFERRED PROVIDER (OPTIONAL)

DOCUMENTS

COPY OF INSURANCE CARD (FRONT)

COPY OF INSURANCE CARD (BACK)

COPY OF AUTHORIZATION

COPY OF MOST RECENT PROGRESS REPORT

COPY OF GROWTH CHART

COPY OF PERTINENT TESTS

COPY OF RELEVANT IMAGING

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