Division of Endocrinology Referral Request Division Phone: 714.509.8634 CHOC Scheduling Line: 888.770.2462 Fax: 855.246.2329 Thank you for referring your patient to the Division of Pediatric Endocrinology.
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How to use or fill out the Endocrinology Referral Request Form - Choc online
Filling out the Endocrinology Referral Request Form - Choc online is a straightforward process designed to ensure that all required information is collected efficiently. This guide provides step-by-step instructions to help you complete the form accurately and effectively.
Follow the steps to fill out the Endocrinology Referral Request Form online.
- Click the ‘Get Form’ button to access the Endocrinology Referral Request Form and open it in your preferred editing platform.
- Enter the patient's information in the designated fields. Indicate if the patient lives with someone other than their legal guardian by selecting 'Yes' or 'No' and providing the relationship if applicable.
- Input the patient's name and date of birth in the appropriate sections.
- Provide the parent or guardian's name and phone number, along with their cell number if available.
- Indicate the patient's insurance information as required.
- Identify if the referral is considered URGENT by selecting 'Yes' or 'No'. If it is urgent, ensure to call the provided number with the necessary clinical information.
- Clearly state the reason for the referral in the provided section.
- Articulate any key questions you want the endocrynology team to answer.
- Choose the appropriate clinic option based on the patient’s needs: General Endocrinology, Growth clinic, or Diabetes clinic. Ensure to provide any required information or documentation for the selected clinic.
- Fill out the referring provider's information, including name, phone, fax, address, and signature with date and time.
- After completing the form, ensure to review all entries for accuracy. You may then save your changes, download the form, print it, or share it as needed.
Complete your documents online today to ensure a smooth referral process.
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