Get Tx Childrens Hospital Consult Request Form 2017-2025

Completing the TX Children's Hospital Consult Request Form online is essential for ensuring that your referral for pediatric consultation is processed smoothly. This guide will walk you through each section of the form, providing clear instructions to help you submit the necessary information.

Follow the steps to accurately complete the consult request form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by filling out the patient information section. Include the patient's last name, first name, age, and date of birth. Ensure you enter the home address along with the city, state, and ZIP code. Indicate whether this is a new patient to Texas Children's by selecting 'Yes' or 'No' if applicable.
3. Provide the primary medical insurance carrier's name and telephone number. If the insurance carrier requires physician referral authorization, answer 'Yes' or 'No' and note that any required authorization should be faxed to the provided number.
4. Next, fill out the parent or guardian information, including their last name, first name, home phone number, work phone number, and cell phone number. If an interpreter is needed, indicate 'Yes' and specify the required language.
5. Complete the referring physician contact information section by providing the physician's name, email address, mailing address, city, state, office phone number, ZIP code, office fax number, and cell phone number. Include the name of the office personnel contact.
6. In the significant medical history section, provide a succinct overview of the reason for the referral, along with any relevant health problems, surgical procedures, significant birth or family history, and allergies. This information is crucial for the consulting team.
7. Once all fields are completed, review the entire form for accuracy. Then, save your changes, download the form, or print it for submission.
8. Finally, fax your completed referral form, along with any pertinent health information, to the General Pediatrics Consult Clinic at 713-396-1995.

Complete the TX Children's Hospital Consult Request Form online to ensure timely processing of your consultation request.