Get Texas Children's Hospital Referral Form 2012-2026

Completing the Texas Children's Hospital Referral Form online can streamline the referral process for patients in need of specialized care. This guide will walk you through each section of the form, providing clear instructions to ensure all necessary information is included.

Follow the steps to successfully complete the referral form.

1. Select the ‘Get Form’ button to access the Texas Children's Hospital Referral Form and open it in your preferred editor.
2. Fill in the date of referral at the top of the form.
3. Complete the patient information section by providing the last name, first name, middle initial, and street address. Ensure all details are printed clearly.
4. Specify the city, state, and zip code of the patient's residence.
5. Indicate if a translator is needed by checking 'Yes' or 'No.' If 'Yes,' write the required language.
6. Enter the name of the parent or guardian, and whether the referral is urgent by selecting 'Y' for yes or 'N' for no.
7. Input the patient's age, date of birth, and gender.
8. Answer whether this is a new patient to Texas Children’s Hospital by selecting 'Yes' or 'No.'
9. Provide contact numbers by filling in the home phone, work phone, and cell phone fields.
10. Complete the referring physician's information by including their name, address, cell phone, office phone, office fax, and email address.
11. Identify the primary insurance carrier and their phone number.
12. If an insurance referral is needed, please indicate that and fax the necessary documentation to 832-825-9332.
13. Specify the patient's diagnosis and check any applicable reasons for evaluation from the list provided.
14. Finally, ensure the referring physician signs the form.
15. Once all sections are completed, save any changes you made to the form, and choose to download, print, or share it as needed.

Complete and submit the Texas Children's Hospital Referral Form online today to ensure your patient receives the necessary care.