Get Scottish Rite Referral

Completing the Scottish Rite Referral is an essential step to accessing specialized care for children. This guide provides clear and comprehensive instructions on how to fill out the referral form effectively to ensure a smooth application process.

Follow the steps to successfully complete the referral form.

1. Press the ‘Get Form’ button to access the referral form and open it in your preferred online platform.
2. Indicate whether the child has previously been a patient at Texas Scottish Rite Hospital for Children by selecting 'Yes' or 'No.' If applicable, provide any relevant medical record number (MR#).
3. Enter the child's full name as it appears on their birth certificate. Fill in necessary details, including gender, age, and religious preference.
4. Provide the child's date of birth and social security number. If the child does not have a social security number, please write 'none.'
5. Indicate if the child speaks English by selecting 'Yes' or 'No.' If 'No,' please specify the child's primary language.
6. Specify with whom the child primarily resides by checking the appropriate box(es) for the father, mother, or managing conservators.
7. If applicable, provide information on the managing conservators, including their contact details and relationship to the child. If there is a court decision affecting custody, please upload the court order.
8. List any family members who have been patients at Texas Scottish Rite Hospital for Children to assist in coordinating appointments and treatment plans.
9. Read and acknowledge the agreement section. Ensure that this section is signed by the natural parent(s) or managing conservator(s).
10. For the physician referral portion, ensure that the referring physician fills out all required details and signs the form.
11. Once all sections are filled out, save your changes. You can download, print, or share the completed form as necessary.

Complete your Scottish Rite Referral online to facilitate the medical care your child needs.