PEDIATRIC SPECIALTY NEW PATIENT FORM Date: ______

PEDIATRIC SPECIALTY NEW PATIENT FORM
OPTION
1 □
2 □
Date: ____________
If faxing a request to a pediatric medical sub-specialty, choose option 2 and fax form to number below. If calling to
schedule an appointment (203-785-4081 #1), we will fax form to you for confirmation.
PHONE OPTION/APPOINTMENT CONFIRMATION:
Your patient has an appointment scheduled with
_______________________ from the _______________________ service on _______________ at _____ AM/PM. Please
provide a brief medical history and current medications then fax this form to the appropriate number listed below ALONG
WITH PERTINENT MEDICAL RECORDS.
□ SELF REFERRED □ PROVIDER REFERRED
FAX OPTION/APPOINTMENT REFERRAL: Please complete this form in its entirety and fax it to the appropriate
number listed below ALONG WITH PERTINENT MEDICAL RECORDS.
CHECK ONE. FAX THE FOLLOWING REFERRALS TO 203-737-7635:
Adolescent Comprehensive Care
Developmental & Behavioral
Adoption
Endocrinology
Hematology/Oncology
MDA/Neuromusclar
NICU GRAD Program
Bone Marrow Transplant
MDA-Cardiology
Bone Clinic
Coagulation Clinic
MDA-Neurology
Aerodigestive Program
Allergy
General Endocrinology
General Hematology
MDA-Orthopedics
Asthma
Immunodeficiency
Obesity/PCOS
General Oncology
MDA-Respiratory
BPD
Type 1 Diabetes
Hemophilia
Type 2 Diabetes
HEROS Clinic
Dialysis Clinic
Neuro-Oncology
General Nephrology
CPAP/BiPap
Exercise Induced
Bronchoconstriction (EIB)
Kidney Transplant
General Respiratory
Tracheostomy/Ventilator
Allergy/Immunology
Cardiology
Adult Congenital Heart Program
Arrhythmia/Pacemaker
GI/Hepatology
Nephrology
Sickle Cell
CF
Cardiogenetics
General GI
General Cardiology
IBD
Heart Failure
Metabolic Liver
General Neurology
Kawasaki Disease
Hepatology
Stroke
Infectious Diseases
Respiratory
Neurology
Sleep Apnea
Rheumatology
Spina Bifida
NOTE: ALL SERVICES LISTED ABOVE ARE INCLUDED IN THE ONE-CALL PROGRAM. SEE FAQ SHEET FOR OTHER PEDIATRIC
PROGRAMS.
Patient Name: ______________________________ Gender: M
Address (1):
Address (2):
Parent/Guardian Name(s):
Phone: (Home)
(Work)
Primary Language if other than English:
Insurance Company Name:
F
DOB: __________
(Cell)
Interpreter Req: □ Yes □ No
ID #:
Brief Medical History/Reason for Referral:
Hospital Discharge:
Medications:
□ Yes □ No
If YES, Specialty Consulted In Hospital:
□ Yes □ No
Labs/Diagnostic Imaging/Records (Please indicate below records you are faxing with this form)
□
□
□
□
Bloodwork
Stool/Urine
Pertinent Office Records/Growth Charts
X-ray/other diagnostic imaging
PCP/Referring Provider Name:
Address:
Phone:
Fax:
□
□
□
□
Cardiac Tests
Neurologic Testing
Immunization Records
Other (specify):
E-mail(optional):
For Yale Office Use Only
Appointment Date:__________ Appointment Time: ________Scheduled Provider:__________________________
Parent/Guardian Notified: □Yes □No: Conversation:
Message:
Date:
Initials:
Final: 8/8/13
For additional copies, go to www.yalepediatrics.org,
www.yalemedicalgroup.org/refer_a_patient, or www.ynhch.org
Yale New Haven Children’s Hospital
Yale Department of Pediatrics
One-Call Program Frequently Asked Questions
1. Which specialties are included in the One-Call Program?
• Currently the following specialties are a part of the One-Call Program.
Adolescent Comprehensive Care Infectious Diseases
•
Adoption
MDA/Neuromusclar
Allergy/Immunology
Nephrology
Cardiology
Neurology
Developmental & Behavioral
NICU GRAD
Endocrinology
Respiratory
GI
Rheumatology
Hematology/Oncology
Spina Bifida
Because we are adding additional specialties to the One-Call Program on a regular basis, you should
always download the latest New Patient Referral Form/Flow Diagram (which includes the list of
specialties included in the One-Call Program) from the web
(http://www.yalemedicalgroup.org/about/refer.html, www.yalepediatrics.org, or www.ynhch.org).
2. How are appointments scheduled?
• Appointments are scheduled in one of three ways.
(1) Call 203-785-4081 Option #1 to schedule appointment or (2) Fax referral to 203-737-7635 or (3)
Enter referral in EPIC.
3. Who can initiate an appointment?
• If scheduling by phone, anyone (referring provider, referring provider office, patient/parent) can call 203785-4081 Option # 1 to schedule the appointment. CALLER MUST KNOW THE PATIENT’S BASIC
DEMOGRAPHIC DATA AND REASON FOR REFERRAL.
• If scheduling by fax, the referring provider must complete the Pediatric Specialty New Patient Form and
fax it to 203-737-7635.
• If scheduling via EPIC, the referring provider or designee must complete all the required fields.
4. How will I know an appointment has been scheduled?
• Whether the appointment is scheduled by phone, fax, or EPIC, the One-Call schedulers will fax a
confirmation to the referring/primary care provider office with the patient’s appointment date/time clearly
marked.
5. Where do I send office notes/pertinent information?
• If the appointment is scheduled by phone, the One-Call schedulers will fax a pre-populated Pediatric
Specialty New Patient Form to the referring/primary care provider office to complete and fax (203-7377635) back with pertinent medical records.
• If the appointment is scheduled by fax, you can fax pertinent medical records at the same time you fax the
completed Pediatric Specialty New Patient Form to the number indicated on the form.
• If the appointment is scheduled via EPIC and there are pertinent medical records that pre-date EPIC, those
records can be scanned in to EPIC by the referring office or faxed to 203-737-7635.
6. What if I want to talk to one of the specialists before making the referral?
• To speak to one of the specialists before making the referral, call the Pediatric Consultative Service at
888-964-4233.
7. What if I want to refer a patient to another pediatric specialty service?
• To refer a patient to another pediatric specialty service, please contact that office directly at the phone
number listed. If you have EPIC in your practice, you can make the referral via EPIC.
Cranio-Facial
203-737-2049
Opthalmology
203-785-2020
Thyroid
203-785-2701
Epilepsy
203-785-3865
Orthopaedics
203-785-2579
Urology
203-785-2815
Neurosurgery
203-785-2809
Pediatric Surgery
203-785-2701