Get Chla Referral Form

This guide provides clear and supportive instructions on how to fill out the Chla Referral Form online. By following these steps, you will ensure that all necessary information is accurately submitted for outpatient service referrals at Children's Hospital Los Angeles.

Follow the steps to complete the Chla Referral Form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by filling out the required physician information in section I. Provide your first name, last name, office address, office phone number, office fax number, and email address. If there is an office contact person other than yourself, include their name.
3. Move on to section II, which focuses on patient and family information. Enter the patient's first and last name, date of birth, and gender. Specify the primary language spoken by the patient. Additionally, provide the first and last name of the parent or guardian, along with their phone and alternative phone numbers. Indicate whether the patient has been seen at CHLA before.
4. In section III, complete the clinical information. Indicate the requested specialty or specialist and provide the reason for the referral. Choose the preferred location from the options available, such as Los Angeles-Main Campus or others.
5. Proceed to section IV to fill out the insurance information. Select the type of insurance the patient has and enter the insurance carrier's name, as well as the subscriber ID. If prior authorization is required, make sure to complete the relevant authorization details.
6. Once all sections are completed, review your entries for accuracy. Make any necessary edits to ensure all required fields are filled correctly.
7. After finalizing the form, you can save changes, download, print, or share the completed form as needed.

Submit your Chla Referral Form online today to ensure efficient processing of your referral.