Get Referral Form - Utah Department Of Health - Health Utah

Filling out the Referral Form for the Utah Department of Health is an important step in initiating services for children with special health care needs. This guide will take you through the process of completing the form step by step, ensuring you provide all necessary information in a clear and organized manner.

Follow the steps to complete the referral form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the date at the top of the form, ensuring it reflects the day you are submitting the referral.
3. Fill in the parent or guardian's name in the appropriate section, along with their address and phone number.
4. Document the medical home provider's name and contact number, ensuring you include the correct phone details.
5. Record the insurance details, including the insurance provider's name and their contact phone number.
6. Enter the fax number of the local CSHCN clinic, ensuring accuracy for timely communication.
7. Indicate who referred the child by filling in the 'Referred By' section, including their contact details and fax number.
8. Describe the concerns or needs by listing any symptoms, delays, or specific issues you want evaluated and assessed.
9. If applicable, note any pertinent tests or labs that have been ordered and include any brief results if completed.
10. Once all sections are filled out accurately, review the information you've entered for completeness.
11. You can then save your changes, download a copy of the form, print it for your records, or share it as needed.

Start completing the Referral Form online today to ensure your child's health needs are addressed.