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                Get Ca Chla Consultation Request Form 2016-2025
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How to fill out the CA CHLA Consultation Request Form online
Filling out the CA CHLA Consultation Request Form online can streamline the process of submitting consultation requests to the Children's Hospital Los Angeles. This guide will provide clear, step-by-step instructions to assist you in accurately completing each section of the form.
Follow the steps to complete the form successfully.
- Click 'Get Form' button to obtain the consultation request form and open it for editing.
- Begin by entering the details for the referring facility at the top of the form. Include the name, address, phone number, and fax number to ensure accurate delivery of the consultation request.
- Fill in the ordering physician’s information, including their name, signature, phone number, and fax number. This identifies the responsible physician for the consultation request.
- Complete the 'Material Submitted' section. This includes mandatory information such as the patient’s first name, last name, age, date of birth, and sex. Ensure all fields are filled out to prevent delays in case review.
- Provide the patient’s Medical Record Number (MRN) and Pathology Number, as well as the number of blocks and slides submitted, and the collection date. This information is necessary for tracking and processing the request.
- In the billing information section, designate a billing contact person and include their institution or facility name, address, phone, fax, and email. Note that direct billing to insurance is not currently an option.
- Review all completed sections for accuracy before finalizing. Once you are satisfied with the information provided, you can save changes, download, print, or share the form as required.
Complete your CA CHLA Consultation Request Form online today for an efficient submission process.
The email format for contacting CHLA usually follows the standard practice of using the format username@chla. This email is essential when you need to send the CA CHLA Consultation Request Form or other important documents. Ensuring you use the correct email format helps to streamline communication and avoid delays in patient referral.
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