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Specialty Clinic Referral

To refer a patient to one of the Children’s Mercy Hospitals and Clinics (CMH) Specialty Clinics, please click on the New Patient Appointment Form below.

  • Print this form and fax it with attachments, or submit it electronically and fax any attachments separately.
  • Forms requiring a signature must be printed, signed, and faxed.
  • Save or print a copy of this form before submitting it electronically.

Each patient is given a “next available” appointment slot. If the scheduled appointment is not soon enough, please contact us.

Please note that Adobe Reader is required to view these forms.

* If you need to schedule two or more appointments on the same day for your patient, please contact the Physician Appointment Line in the Contact Center at (816) 234-3700 or (800) 800-7300 and ask for the “Provider Resource Nurse”.

pdf logo New Patient Appointment Form  (revised April 2012)
pdf logo Quick Reference Guide

The following clinics have additional information regarding the referral process and/or additional forms to be submitted with the appointment request or prior to the appointment.

Asthma, Allergy, Immunology
Referral Process for a NEW PATIENT:
  • To refer a new patient to Asthma, Allergy & Immunology, please complete the New Patient Appointment Form to submit electronically.
  • The Asthma, Allergy & Immunology staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Asthma, Allergy & Immunology Department direct at (816) 234-1600 (press 4 to speak with someone).
Referral Tips:
  • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
  • You must press PRINT to keep a copy of the New Patient Appointment Form.
  • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
Specialty Form(s): to complete for Pre-Visit Appointment:
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Asthma, Allergy & Immunology: (816) 234-1600 (press 4 to speak with someone)
For more information see the Asthma, Allergy & Immunology website
Blood and Marrow Transplant Program
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Blood and Marrow Transplant Program (BMT), please call the BMT Program at (816) 234-3265.
  • Inform the receptionist that you are a medical caregiver wishing to discuss or refer a patient to be seen by a BMT physician.
  • If readily available, a BMT physician will speak to you immediately; otherwise they will return your call at their first opportunity.
  • Please inform the receptionist if this is an emergent matter needing to be seen immediately.
  • The BMT staff will contact the parent to schedule an appointment (please be sure to provide the family’s contact information to the receptionist when you call). They will also notify the PCP the date/time of the appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the BMT Program direct at (816) 234-3265.
Referral Tips:
  • If available, please fax copies of the pertinent medical records, physical exam information and/or lab results to the BMT Program at (816) 855-1700.
  • If surgical biopsies have already been obtained, slides and specimens will need to be forwarded to the Children’s Mercy Pathology department for review and possible further diagnostic evaluation. For additional information on forwarding to Pathology please call (816) 234-3234. Prior to initiation of therapy, all patients who have had their cancer diagnosed outside of Children’s Mercy will have their pathologic specimens reviewed. The earliest receipt of these will permit the process to proceed more quickly.
  • If radiologic evaluations have been performed prior to referral, either copies or originals of the X-ray exams need to be forwarded to the Pediatric BMT physician. This may either be by courier service or by the family bringing the films with them to their initial visit at Children’s Mercy. The earliest receipt of these will permit the process to proceed more quickly.
  • BMT only accepts patients who are referred by their healthcare provider. Parents or family who wish their child be seen by a pediatric BMT physician should request their physician or medical caregiver to contact us directly.
Specialty Form(s) to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact:
  • Blood and Marrow Transplant Program Team: (816) 234-3265
For more information see the Blood and Marrow Transplant Program website
Burn Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Burn Clinic, please call (816) 234-3520 (press 4 to speak with someone).

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Burn Clinic direct at (816) 234-3520 (press 4 to speak with someone).
Referral Tips:
  • None
Specialty Form(s) to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact:
  • Burn Clinic: (816) 234-3520 (press 4 to speak with someone)
For more information see the Burn/Trauma Care Section website
Cardiology Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Cardiology Clinic, please complete the New Patient Appointment Form and submit electronically.
  • The Contact Center staff will contact the parent to schedule an appointment at a convenient time and location for the patient and family. The Contact Center staff will also notify the PCP the date/time of the appointment.
  • To schedule an Excercise Stress Test, please fill out the form below and fax to the Cardiology Clinic at (816) 855-1745

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Cardiology Clinic directly at (816) 234-3880
Referral Tips:
  • To reach the cardiologist on duty regarding a specific patient during Monday through Friday daytime hours, please call the cardiology clinic at (816) 234-3880 and press option 3 to speak with someone immediately.
  • To speak to the cardiologist on call in the evening, nights or weekends, call 1-800-GO-MERCY and ask to speak to the cardiologist on call.
  • When completing the New Patient Appointment Form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
  • You must press PRINT to keep a copy of the New Patient Appointment Form.
  • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
Specialty Form(s): to complete for Pre-Visit Appointment:
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Cardiology Clinic: (816) 234-3880 (press 4 to speak with someone)
For more information see the Cardiology Section website
Cleft Palate - Craniofacial Clinic (CLPC)
Referral Process for a NEW PRE-NATAL CONSULTATION:
  • To refer a new patient to the Cleft Palate – Craniofacial Clinic (CLPC), please call the Fetal Health Center at (816) 346-1343.
  • If readily available, the Fetal Health Center scheduler will speak to you immediately; otherwise, they will return your call at their first opportunity.
  • Please inform the Fetal Health Center scheduler if this is an emergent matter needing to be seen immediately.
  • The Fetal Health Center staff will contact the parent to schedule a pre-natal consultation appointment (please be sure to provide the family’s contact information to the receptionist when you call). They will also notify the PCP the date/time of the appointment.

Referral Process for a NEW CLPC PATIENT:
  • To refer a new patient to the Cleft Palate – Craniofacial Clinic (CLPC), please call the CLPC at (816) 460-1086.
  • Refer patients for Cleft Lip, Cleft Palate, Craniofacial Anomalies, Craniofacial Syndromes and suspected Cleft Palate due to nasal speech.
  • If readily available, the CLPC scheduler will speak to you immediately; otherwise, they will return your call at their first opportunity.
  • Please inform the CLPC scheduler if this is an emergent matter needing to be seen immediately.
  • The CLPC staff will contact the parent to schedule a team appointment (please be sure to provide the family’s contact information to the CLPC scheduler when you call). CMH will also notify the PCP the date/time of the appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Cleft Palate – Craniofacial Clinic (CLPC) directly at (816) 460-1086.
Referral Tips:
  • If available, please fax copies of the pertinent medical and educational records, physical exam information and/or lab results to the CLPC Program at (816) 234-3291. When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
  • The Cleft Palate-Craniofacial Clinic has two locations to serve patients:
    1. Children’s Mercy Hospital
      2401 Gillham Road, Outpatient Center
      Kansas City, MO 64108
    2. Children’s Mercy South
      5520 College Blvd., Suite 370
      Overland Park, KS 66211
  • It is important that the family or PCP’s office notify us of current phone number and/or address in order to schedule the next team visit.
Specialty Form(s): to complete for Pre-Visit Appointment:
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Cleft Palate-Craniofacial Clinic (CLPC): (816) 460-1086
For more information see the Cleft Palate Clinic website
Cystic Fibrosis Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Cystic Fibrosis Clinic, please call the Cystic Fibrosis clinic at (816) 983-6490 and press 4 to speak with someone. The CF clinic will take new patients only with a confirmed diagnosis of Cystic Fibrosis.
  • If you have a patient with an Abnormal Newborn Screen for Cystic Fibrosis, please follow the guidelines given on the State referral form (provided to patient after birth). For further questions you may contact the CF clinic directly at (816) 983-6490.
  • If you are trying to determine if the patient has Cystic Fibrosis, you may order a Sweat Test by calling the Contact Center at (816) 234-3700 or (800) 800-7300. Sweat Tests are performed in the Main Lab at Children’s Mercy, not in the CF clinic. Give the Lab your contact number so they can call you with the results.
  • If the Sweat Test is positive, call the Cystic Fibrosis Clinic at (816) 983-6490 and request to speak with the Cystic Fibrosis nurse to schedule a new CF diagnosis.
  • If the patient continues to exhibit Pulmonary symptoms, refer them to the Pulmonology clinic by completing the New Patient Appointment Form and submitting electronically. 
  • The Contact Center will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Pulmonology Clinic direct at (816) 983-6490 (press 4 to speak with someone).
Referral Tips:
  • When completing this form by hand, please also fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776
  • Please fax clinic notes describing the patient’s symptoms along with lab results, genetic testing and x-ray reports to the Contact Center at (816) 855-1776
  • The Cystic Fibrosis Clinic is available to serve your patient at the below location:
    • Children’s Mercy Hospital
      2401 Gillham Road
      Kansas City, MO

      Monday through Wednesday afternoons & Thursday and Friday mornings
  • Please specify appointment location preference on the New Patient Appointment Form
Specialty Form(s): to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact staff in the either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Cystic Fibrosis Clinic: (816) 983-6490 (press 4 to speak with someone)
For more information see the Pulmonary & Sleep Medicine website
Dental Clinic
Referral Process for a NEW PATIENT:
  • Contact Dental Clinic Manager for questions about a referral at (816) 983-6804
Dermatology Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Dermatology Clinic, please complete the New Patient Appointment Form and submit electronically. 
  • The Contact Center staff will contact the parent to schedule an appointment for the patient and will also notify the PCP the date/time of the appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Dermatology Clinic at (816) 234-3468
Referral Tips:
  • No forms, labs, or radiologic studies are required to refer a new patient to the Dermatology Clinic
  • If previous cultures and/or therapies have been done, please include results and brief summary on the referral form
  • For a patient to be scheduled into the Laser Surgery Clinic, they must first be scheduled in the Dermatology Clinic for an evaluation
Specialty Form(s): to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Dermatology Clinic: (816) 234-3020 (press 4 to speak with someone)
For more information see the Dermatology Section website
Developmental and Behavioral Sciences Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Developmental and Behavioral Sciences Clinic, please instruct the parent to call either Children’s Mercy Hospital at (816) 234-3674 (press 4 to speak with someone) or call Children’s Mercy South at (913) 696-8261 (press 4 to speak with someone). An assistant will gather necessary demographic information and will provide to a Social Worker who will contact the parent for more detailed information.
  • The Social Worker will review for applicability and forward information to providers for further review.
  • When applicable, the parent will be contacted and paperwork sent to the parent.
  • If not applicable, the Social Worker will contact the parent with community resources.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please instruct the parent to call either Children’s Mercy Hospital at (816) 234-3674 (press 4 to speak with someone) or call Children’s Mercy South at (913) 696-8261 (press 4 to speak with someone). An assistant will gather necessary information and provide to the administrative staff for scheduling. The parent is contacted with details regarding the scheduled appointment(s).
Referral Tips:
  • Parents may self refer patients to this Clinic.
  • The Developmental and Behavioral Sciences Clinic has two locations to serve patients:
    1. Children’s Mercy Hospital
      2401 Gillham Road, Kansas City, MO
    2. Children’s Mercy South
      5520 College Blvd. Suite 130, Overland Park, KS
Specialty Form(s) to complete for Pre-Visit Appointment:
  • Administrative Staff will send the appropriate form(s) to parents upon approval from the accepting provider. These forms must be returned to the clinic prior to the appointment being scheduled.
For questions about a referral, contact staff in either of the below departments:
  • Children's Mercy Hospital: (816) 234-3674 (press 4 to speak with someone)
  • Children's Mercy South: (913) 696-8261 (press 4 to speak with someone)
For more information see the Developmental & Behavioral Sciences Section website
Down Syndrome Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Down Syndrome Clinic, please complete the New Patient Appointment Form to submit electronically.
  • The Down Syndrome Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Down Syndrome Clinic directly, at (816) 234-3771.
Referral Tips:
  • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
  • You must press PRINT to keep a copy of the New Patient Appointment Form.
  • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
Specialty Form(s): to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Down Syndrome Clinic: (816) 234-3771
For more information see the Down Syndrome Clinic website
Eating Disorders Center
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Eating Disorders Center, please complete the New Patient Appointment Form and submit electronically.
  • The Eating Disorders Center staff will contact the parent to schedule an appointment at a convenient time and location for the patient and family. The Contact Center staff will also notify the PCP the date/time of the appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Eating Disorders Center directly at (913) 696-5070 (press 4 to speak with someone).
Referral Tips:
  • Please instruct parent/patient to contact the EDC for intake/assessment at (913) 696-5070
  • Referring providers can contact the EDC to relay referral information
Specialty Form(s): to complete for Pre-Visit Appointment:
  • None
  • If available, please fax labs, growth charts, and ongoing treatment plan.
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • • Eating Disorders Center: (913) 696-5070 (press 4 to speak with someone)
For more information see the Eating Disorders Center website.
Endocrine/Diabetes Clinic
Referral Process for a NEW PATIENT:
  • To refer a patient with suspected Diabetes
    • If you suspect a new onset of Type 1 or Type 2 diabetes, call 800-GO-MERCY ((800) 466-3729) at Children’s Mercy Hospital and ask to speak to the endocrinologist on call.
    • If the child has Type 1 or Type 2 diabetes, but is new to your practice and has never been seen at Children’s Mercy Hospital, follow the same process for any other new patient.
  • To refer a patient with suspected Non-Diabetes
    • Choose the recommended guideline for the diagnosis
    • Follow the recommended guidelines for screening laboratory and/or radiology tests
    • Once you have reviewed the results of the testing and spoken with the parents about the need for an endocrinologist appointment, please fax the documents listed below to the Contact Center at (816) 855-1776:
      1. New Patient Appointment Form
      2. The test results – (If the tests were done at Children’s Mercy Hospital, do not fax the results. Write a note on the referral form and we will find the results in the patient’s medical record at Children’s Mercy Hospital.)
      3. A growth chart
      4. The most recent clinic visit notes

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Endocrine/Diabetes Clinic direct at (816) 234-1660 (press 4 to speak with someone).
Referral Tips:
  • For the purpose of triage, upon receipt of the screening test results, one of the endocrinologists will review the child’s test results, their growth history, and the most recent clinic visit notes. The doctor will determine if the child needs to be seen within one to two weeks or can wait until the “next available” appointment. The timeline for a “next available” appointment may be up to three months.
  • Due to the volume of new referrals, the triage process can take up to five business days. Once the triage process is completed, the Contact Center will call the parents for the appointment. The nurse scheduler in the Endocrine Clinic will call the parents if the child needs to be seen sooner. The referring provider will be notified of the appointment date by either the Contact Center staff or Endocrine Clinic staff.
  • The endocrinologist on call is available 24/7 by contacting 1-800-GO-Mercy ((800) 466-3729). Contact them directly if you suspect the child needs to be seen urgently.
  • When completing the New Patient Appointment Form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
Specialty Form(s): to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Endocrine/Diabetes Clinic: (816) 234-1660 (press 4 to speak with someone)
For more information see the Endocrine/Diabetes Clinic website
ENT Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the ENT clinic, please complete the New Patient Appointment Form to submit electronically.
  • The Contact Center nurses will place the child on the Request List for an appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the ENT clinic directly, at (816) 234-3040 (press 4 to speak with someone).
Referral Tips:
  • Due to the large volume of referrals it may be several months before your patient is given an appointment date and time. Your patient will be called in the order they were placed on our request list for an appointment. It is imperative they notify us of any change in phone number so that we may reach them when it is time to schedule. The triage nurse in the ENT Clinic regularly reviews pending requests with our ENT physicians and will call the parents if the child needs to be seen sooner or cannot wait.
  • The ENT physician on call is available 24/7 by contacting 1-800-GO-Mercy ((800) 466-3729). Contact them directly if you suspect the child needs to be seen urgently.
  • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
  • You must press PRINT to keep a copy of the New Patient Appointment Form.
Specialty Form(s): to complete for Pre-Visit Appointment:
  • For all referrals to be evaluated for Adenotonsillar Hypertrophy please complete and fax the Pharyngitis/Tonsillitis Form to Children’s Mercy Medical Records One Fax at (816) 701-4035.
  • For all referrals to be evaluated for Acute/Recurrent Otitis Media please complete and fax the BMT Form to Children’s Mercy Medical Records One Fax at (816) 701-4035.
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • ENT Clinic: (816) 234-3040 (press 4 to speak with someone)
For more information see the Otolaryngology Section website
Failure to Thrive (Ready, Set, Grow) Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Failure To Thrive (Ready, Set, Grow) Clinic, you may:
    • Download and complete the Ready, Set, Grow New Patient Information Sheet and fax it to the Access Reps at Broadway at (816) 960-2896 - OR - Contact the Ready, Set, Grow Clinic directly at (816) 960-3095. A RSG New Patient Information Sheet will be faxed to you for completion.
    • Fax pertinent patient records (including weight/height data, growth charts, labs/tests completed and their results, recent notes, etc.) to Children's Mercy Hospital's Medical Records at (816) 701-4035. (NOTE: if labs/tests were completed at Children's Mercy Hospital, there is no need to fax the results; please let us know and we will locate them in Cerner)
    • To help facilitate patient compliance, the Ready, Set, Grow scheduler will contact you with an appointment date and time for the patient so you can inform the family. If you feel the patient needs to be seen sooner than the date provided, please call the Ready, Set, Grow nurse at (816) 960-3095.
    • If the appointment date provided to you is not acceptable to the family, the parent/caretaker needs to contact the Ready, Set, Grow scheduler at (816) 960-3095 to be rescheduled; you will be notified by fax of the appointment change.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Ready, Set, Grow Clinic at (816) 960-3095.
Referral Tips:
  • Any information regarding the interventions you have attempted is appreciated.
  • Please feel free to offer any insight you have into the patient/family.
  • Height/weight data, lab results and recent note information is required prior to seeing the patient.
  • Please provide any pertinent information regarding particular concerns.
Specialty Form(s) to be completed BY PATIENT'S FAMILY prior to appointment will be mailed to the family's address you provide:
  • Feeding Information Packet – This is a questionnaire with questions regarding specific feeding/eating information as well as questions to provide insight into the family's perceptions/concerns.
  • 24-hour Food Recall – This provides the family a form to record feeding information for the 24-hour period prior to the appointment (including feeding times, location of feedings and who the patient was with while eating).
For questions about a referral, contact staff in the below department:
  • Ready, Set, Grow Clinic: (816) 960-3095
Gastroenterology Clinic
Referral Process for a NEW PATIENT: Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Gastroenterology Clinic at (816) 234-3066 (press 4 to speak with someone).
Referral Tips:
  • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
  • For a patient to be scheduled for a GI procedure, they must first be evaluated in the Gastroenterology Clinic.
  • For a patient to be scheduled in the Abdominal Pain Clinic, they must call the Abdominal Pain Clinic Nurse Line at (816) 234-3078.
Specialty Form(s) to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Gastroenterology Clinic: (816) 234-3066 (press 4 to speak with someone)
  • Abdominal Pain Clinic Nurse Line voicemail: (816) 983-6975
For more information see the Gastroenterology Section website
Genetics Clinic
Referral Process for a NEW PATIENT:
  • To refer a patient for syndrome identification:
    • Choose the recommended guideline for the diagnosis.
    • Follow the recommended guidelines for needed labs, imaging and/or other exams.
    • Once you have reviewed the results of the needed studies and spoken with the parents about the need for a Genetics appointment, please fax the documents listed below to the Contact Center at (816) 855-1776.
      1. New Patient Appointment Form
      2. The test and/or exam results – (If the tests were done at Children's Mercy Hospital, do not fax the results. Write a note on the referral form and we will find the results in the patient’s medical record at Children's Mercy Hospital.)
  • To refer a patient for evaluation of an inborn error of metabolism or suspected mitochondrial disorder:
    • Once you have spoken with the parents about the need for a Genetics appointment, please fax the documents listed below to the Contact Center at (816) 855-1776.
      1. New Patient Appointment Form
      2. All pertinent lab test results – (If the tests were done at Children's Mercy Hospital, do not fax the results. Write a note on the referral form and we will find the results in the patient’s medical record at Children's Mercy Hospital.)
      3. A growth chart
      4. The most recent clinic visit notes

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Genetics Clinic directly at (816) 234-3771
Referral Tips:
  • If you are unsure whether you should follow the referral process for syndrome identification or an evaluation of an inborn error of metabolism or suspected mitochondrial disorder, please contact the clinic at (816) 234-3771 and ask to speak with a genetic counselor who can determine what information is needed.
  • For the purpose of triage, upon receipt of the referral form, one of the Genetic counselors will review the child's medical records and test results. The Genetic Counselor will determine if any additional labs, imaging or exams are needed prior to proceeding with the referral and will communicate that information to the referring provider. Once all of the requested information is received, the child will be placed on the waiting list for the "next available" appointment. The timeline for a "next available" appointment may be up to six months.
  • Due to the volume of new referrals, the triage process can take up to five business days. Once the triage process is completed, the Genetic Counselor will call the parents to discuss the referral and to confirm the child’s placement on the waiting list for an appointment pending receipt of needed labs/records. The nurse scheduler in the Genetics Clinic will call the parents to schedule an appointment when one is available. The referring provider will be notified of the appointment date by the Genetics Clinic staff.
  • If you suspect the child needs to be seen urgently, you may contact the Geneticist or Genetic Counselor on call at (816) 234-3290 during normal business hours. After hours, the Geneticist on call is available 24/7 by contacting 1-800-GO-Mercy ((800) 466-3729).
  • When completing the New Patient Appointment Form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
Specialty Form(s): to complete for Pre-Visit Appointment:
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Genetics Clinic: (816) 234-3771
For more information see the Genetics Clinic website
Hearing and Speech Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to Hearing and Speech, please complete the New Patient Appointment Form to submit electronically.
  • For most appointments, the Contact Center staff will contact the parent to schedule the appointment at a convenient time and location for the patient and family. The Contact Center staff will also notify the PCP the date/time of the appointment.
  • For Auditory Branistem Response Sedated (ABRS), Cleft Palate-Craniofacial Clinic (CLPC), Flexible Fiberoptic Video Nasopharyngoscopy (FFVN) appointments, and Reading/Academic/Language Evaluation appointments, the Hearing and Speech staff will contact the parent to schedule the appointment.
  • Contact Radiology to schedule an Oral-Pharyngeal Motility Study at (816) 234-3272.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Hearing and Speech Clinic direct at (816) 234-3677 (press 4 to speak with someone).
Referral Tips:
  • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
  • You must press PRINT to keep a copy of the New Patient Appointment Form.
  • Please provide the patient’s medical concerns and history as new patients are scheduled by procedure type.
  • Please fax any pertinent test results with this form, if available, to the Contact Center at (816) 855-1776.
  • Parents may self-refer patients to this clinic.
  • If a child is being referred for failed hearing screening with no other concerns, please schedule a hearing evaluation in the Hearing and Speech Clinic prior to ENT referral.
  • The Hearing and Speech Clinic has three locations to serve patients:
    1. Children’s Mercy Hospital
      2401 Gillham Road, Outpatient Center – 3rd Floor
      Kansas City, MO 64108
    2. Children’s Mercy Northland
      501 NW Barry Road
      Kansas City, MO 64155
    3. Children’s Mercy South
      5520 College Blvd., Suite 370
      Overland Park, KS 66211
  • The Oral Pharyngeal Motility (OPM) Study is a multi-disciplinary procedure: Scheduling is completed through the Radiology scheduler at (816) 234-3270. Parents receive a pre-visit OPM study questionnaire and should return it prior to the appointment.
  • Auditory Brainstem Response Sedated (ABRS) Test: Scheduling is completed by Hearing and Speech staff. Please fill out the New Patient Appointment Form and fax to (816) 234-3291. Hearing and Speech Clinic staff will call the family to obtain patient history prior to scheduling the test for the patient. Patients who have been tested outside of Children’s Mercy will be scheduled for a Pre-Sedation Appointment to attempt behavioral testing prior to sedation per clinic guidelines.
  • For Cleft Palate Clinic appointments, see Cleft Palate Clinic specialty center.
  • Flexible Fiberoptic Video Nasopharyngoscopy (FFVN): Scheduling is completed by Hearing and Speech staff. Please fill out the New Patient Appointment Form and fax to (816) 234-3291. Patients will be scheduled for a Perceptual Speech Evaluation appointment prior to scheduling a FFVN appointment to determine appropriateness for FFVN testing per clinic guidelines.
  • For Reading/Academic/Language Evaluation appointments: Please fill out the New Patient Appointment Form and fax to (816) 234-3291 along with any prior language testing results and/or a school IEP/504 Plan/Reading Plan that the patient may currently have. Hearing and Speech Clinic staff will call the family to schedule the appointment. A questionnaire packet will be mailed to the patient that should be filled out and returned prior to the appointment. They will also notify the PCP if the date/time of the appointment.
Specialty Form(s): to complete for Pre-Visit Appointment:
For questions about a referral, contact staff in either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Hearing and Speech Clinic: (816) 234-3677 (press 4 to speak with someone)
For more information see the Hearing and Speech website
Hematology/Oncology Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Hematology/Oncology Clinic, please call (816) 234-3265 and ask for the physician taking referral calls. Physician to physician calls are required for new patients.
  • The Hematology/Oncology Clinic staff will contact the parent to schedule the appointment following a Physician to Physician discussion.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Hematology/Oncology Clinic directly, at (816) 234-3460.
Referral Tips:
  • Call (816) 234-3265 for a new patient referral and ask to speak to the physician taking referral calls.
Specialty Form(s): to complete for Pre-Visit Appointment:
  • none
For questions about a referral, contact staff in the below department:
  • Hematology/Oncology office: (816) 234-3265
For more information see the Hematology/Oncology Section website
Individualized Pediatric Theraputics Clinic (IPTC)
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Individualized Pediatric Therapeutics Clinic, please contact Kelly Hodges, RN, Ambulatory Charge Nurse, at (816) 855-1960, prior to completing the New Patient Appointment Form
  • Complete the New Patient Appointment Form and submit electronically
  • The Individualized Pediatric Therapeutics Clinic staff will contact the parent to schedule an appointment and will also notify the PCP the date/time of the appointment

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Charge Nurse direct at (816) 855-1960
Referral Tips:
  • Prior to filling out any forms, please contact the Charge Nurse regarding patient referral to the IPTC
Specialty Form(s): to complete for Pre-Visit Appointment:
  • Please talk to the Charge Nurse for the IPTC for information regarding forms needed
For questions about a referral, contact staff in the either of the below departments:
  • Contact Center: (816) 234-3700 or (800) 800-7300
  • Individualized Pediatric Theraputics Clinic: (816) 855-1960
For more information see the Personalized Medicine website
Infectious Diseases
Infectious Diseases Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Infectious Diseases Clinic, please complete the New Patient Appointment Form and submit electronically.
  • The Infectious Diseases Clinic staff will contact your practice to confirm the appointment so you can then contact the family. Alternatively, if you want us to contact the family regarding date/time of appointment, let us know at that time.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a follow-up patient, please have the parents contact the Infectious Diseases Clinic at (816) 983-6325
Referral Tips:
  • *PLEASE NOTE* Infectious Diseases Clinic appointments are booked by the infectious diseases nurse.
  • Patients are booked in the next, first available appointment slot. Wait time to get an appointment is generally under 2 weeks. For urgent referrals, practitioners may call 1-800-GO-MERCY (800) 466-3729) to speak with the Infectious Diseases physician on-call.
  • Please inform parents to bring a list of all medications the child is taking, including vitamins, minerals and over the counter medications, along with their insurance or Medicaid card and co-pay.
  • Please inform parents to bring their child's immunization record.
Specialty Form(s) to complete for Pre-Visit Appointment:
  • None
For questions about a referral, contact:
  • Infectious Diseases Clinic: (816) 983-6325
For more information see the Infectious Diseases Section website
Travel Medicine Clinic
Referral Process for a NEW PATIENT:
  • To refer a new patient to the Travel Medicine Clinic, please complete the New Patient Appointment Form to submit electronically OR call the Travel Medicine Clinic at (816) 802-1100 and ask to speak to the practitioner taking new referrals.
  • The Travel Medicine Clinic staff will contact the parent to gather more information and to schedule an appointment.

Referral Process for a FOLLOW-UP PATIENT:
  • To refer a patient, for an illness after travel, please use the Provider Portal for the Infectious Disease Clinic or contact them directly, at (816) 234-6325.
Referral Tips:
  • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to Attn: Shirley/Infectious Diseases at (816) 346-1328.
  • You must press PRINT to keep a copy of the New Patient Appointment Form.
  • Patients are booked in the next, first available appointment slot. A clinic visit a minimum of 6 weeks prior to date of travel is preferred. For more urgent referrals contact:
    • The Travel Medicine Clinic: (816) 802-1100
    • Contact Center: (816) 234-3700 or (800) 800-7300
  • Please fax a copy of the patient’s immunization record to Attn: Shirley/Infectious Diseases at (816) 346-1328.
  • Please have the parents bring a list of all medications the child is taking including vitamins, minerals and over the counter medications.
  • PLEASE NOTE – Healthy Departures is located at Children’s Mercy South in the Specialty Clinics
Specialty Form(s): to complete for Pre-Visit Appointment:
  • Please encourage the parents to call The Travel Medicine Clinic and speak to our staff so they can fill out and submit the appropriate Patient History form prior to their appointment.
    Integrative Pain Management Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Integrative Pain Management Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Integrative Pain Management Clinic staff will contact the parent to review the process for a new patient appointment and will send out pre-visit materials with a return mail envelope.
    • Once pre-visit questionnaires are received, Integrative Pain Management Clinic staff will contact the parent to schedule an appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Integrative Pain Management Clinic directly at 816-983-6750 (press 1 to speak with the scheduler).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at 816-855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • Integrative Pain Management Clinic staff will send a pre-visit packet, including questionnaires, to families of new patient referrals.  Once pre-visit questionnaires are received back, Integrative Pain Management Clinic staff will contact the parent to schedule an appointment.
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Integrative Pain Management:  816-983-6750 (press 1 for scheduling)
    For more information see the Integrative Pain Management website
    International Adoption Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the International Adoption Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The International Adoption Clinic staff will contact the parent to schedule the appointment and the Contact Center will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the International Adoption Clinic at (816) 983-6325 (press 4 to speak with someone)
    Referral Tips:
    • A physician referral is not needed for the International Adoption Clinic. Referrals can be made by parent request by a direct call to the International Adoption Clinic at (816) 983-6325.
    Specialty Form(s) to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • International Adoption Clinic: (816) 983-6325 (press 4 to speak with someone)
    For more information see the International Adoption Clinic website
    Laser Surgery Clinic
    Referral Process for a NEW PATIENT:
    • Patients need to be evaluated in the Dermatology Clinic prior to being scheduled in the Laser Surgery Clinic
    • Call the Dermatology Clinic to schedule your patient for an evaluation. (816) 234-3020 (press 4 to speak with someone)

    Referral Tips:
    • None
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about the Laser Surgery Clinic, contact staff in the below department:
    • Dermatology Clinic: (816) 234-3020 (press 4 to speak with someone)
    For more information see the Dermatology Section website
    Mild Traumatic Brain Injury Clinic
    Notes: Children commonly seen in the Mild Traumatic Brain Injury Clinic include those with:
    • Mild traumatic brain injuries
    • Concussions
    • Injury greater than 3 weeks with prolonged symptoms but less than 9 months
    • 3 years up to 18 years (Still in high school)
    • Sports related and non sports related injuries (such as falls, accidents, etc.)
    • Anyone who had an overnight stay in the hospital after concussion
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Mild Traumatic Brain Injury Clinic, please complete the MTBI Form and fax to (816) 855-1776. Make sure all areas are completely filled out.
    • Please fax any MRI's, CT's, previous ImPACT testing results, clinic/visit notes related to this injury, and discharge summary if patient was admitted to the hospital to (816) 855-1776.
    • The Contact Center staff will contact the parent to schedule an appointment.
    Referral Tips:
    • The Mild Traumatic Brain Injury Clinic is located at Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO in the Special Care/Rehab Medicine Clinic.
    • Clinic is held Wednesdays
    • When completing the Rehabilitation Referral Form, please include details in the Notes/Special Instructions section regarding:
      1. When the accident occurred.
      2. What happened with the accident
      3. What symptoms the patient is having
      4. Family or personal history of migraine.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in the below departments:
    • Rehab Department: (816) 234-3970
    Nephrology
    Antenatal Kidney Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Antenatal Kidney Clinic, please complete the New Patient Appointment Form to submit electronically
    • The Nephrology Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Kidney Center directly, at (816) 234-3030 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Kidney Center: (816) 234-3030 (press 4 to speak with someone)
    For more information see the Nephrology Section website
    Bone and Mineral Disorders Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Bone and Mineral Disorders Clinic, please complete the New Patient Appointment Form to submit electronically
    • The Hypertension Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Kidney Center directly, at (816) 234-3030 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Kidney Center: (816) 234-3030 (press 4 to speak with someone)
    For more information see the Nephrology Section website
    Enuresis Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Enuresis Clinic, please complete the New Patient Appointment Form to submit electronically
    • The Hypertension Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Kidney Center directly, at (816) 234-3030 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Kidney Center: (816) 234-3030 (press 4 to speak with someone)
    For more information see the Nephrology Section website
    Hypertension Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Hypertension Clinic, please complete the New Patient Appointment Form to submit electronically
    • The Hypertension Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Kidney Center directly, at (816) 234-3030 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Kidney Center: (816) 234-3030 (press 4 to speak with someone)
    For more information see the Nephrology Section website
    Kidney Center
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Kidney Center, please complete the New Patient Appointment Form to submit electronically
    • The Nephrology Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Kidney Center directly, at (816) 234-3030 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Kidney Center: (816) 234-3030 (press 4 to speak with someone)
    For more information see the Nephrology Section website
    Neurology Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Neurology Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Contact Center staff will contact the parent to schedule the appointment and will also notify the PCP of the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • • To refer a follow-up patient, please have the parents contact the Neurology Clinic directly at (816) 234-3490 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Neurology Clinic: (816) 234-3490 (press 4 to speak with someone).
    For more information see the Neurology Section website
    Neurosurgery Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Neurosurgery Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Neurosurgery Clinic staff will contact the PCP with the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Neurosurgery Clinic at (816) 983-6739
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Neurosurgery Clinic: (816) 983-6739
    For more information see the Neurosurgery Clinic website
    Nutrition Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Nutrition Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Nutrition Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Nutrition Clinic direct at (816) 234-3468 (press 4 to speak with someone)
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Nutrition Clinic: (816) 234-3468 (press 4 to speak with someone)
    For more information see the Nutrition Services website
    Ophthalmology Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Ophthalmology Clinic, please complete the New Patient Appointment Form to submit electronically.
    • The Ophthalmology Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Ophthalmology Clinic directly, at (816) 234-3046 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in the below department:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    For more information see the Ophthalmology Clinic website
    Orthopaedic Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Orthopaedic Clinic, please complete the New Patient Appointment Form and press SUBMIT and the form will be faxed to the Contact Center at Children's Mercy Hospital
    • The Orthopaedic Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Orthopaedic Clinic directly, at (816) 234-3075 (press 1 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • If this referral is a result of an injury, please include the date the injury happened.
    • Please fax x-ray/MRI/CT reports with this form, if available, to the Contact Center at (816) 855-1776.
    • If referring for Scoliosis, please fax spinal films to the Contact Center at (816) 855-1776.
    • If the tests were done at Children's Mercy Hospital, do not fax the results. Write a note on the referral form and we will find the results in the patient's medical record at Children's Mercy Hospital.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Orthopaedic Clinic: (816) 234-3075 (press 1 to speak with someone)
    For more information see the Orthopaedic Clinic website
    Pediatric Care Clinic (PCC)
    Referral Process:
    • To refer a new patient to a General Pediatrician in the Pediatric Care Clinic (PCC), please complete the New Patient Appointment Form and submit electronically.
    • The PCC staff will contact the parent to schedule the appointment
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776
    • Please fax lab results and/or other test results and pertinent progress notes with this form, if available, to the Contact Center at (816) 855-1776
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Pediatric Care Clinic: (816) 960-3050 (press 4 to speak with someone)
    Perinatal Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Perinatal Clinic, please complete the Perinatal Clinic Referral Form and fax it to the Perinatal Clinic at (913) 696-5005.
    • The Perinatal Clinic staff will contact the parent to schedule the appointment and will also notify the Referring Provider the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT (must be actively followed in the Special Care Clinic):
    • To refer a follow-up patient, please have the parents contact the Perinatal Clinic at (913) 696-5000.
    Referral Tips:
    • Please fax lab results and/or other test results with this form, if available, to the Perinatal Clinic.
    • For more information please see the Fetal Health Center Fact Sheet (for providers).
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Perinatal Clinic: (913) 696-5000
    For more information see the Fetal Health Center website
    Physical and Occupational Therapy Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Physical and Occupational Therapy Clinic, please complete the New Patient Appointment Form, have your provider sign the form and fax to the Contact Center at Children's Mercy Hospital, (816) 855-1776.
    • The PT/OT Clinic staff will contact the parent to schedule the appointment.
    • A copy of the PT/OT Evaluation report will be faxed to the referring physician once the evaluation is complete.
    Referral Tips:
    • A physicians order is required for scheduling of PT or OT evaluations, therefore, please have your provider sign at the bottom of the New Patient Appointment Form, prior to faxing to the Contact Center.
    • When completing this form by hand, please also fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • PT and OT services are available at 3 locations to serve patients:
      1. Children’s Mercy Hospital
        2401 Gillham Road, Kansas City, MO
      2. Children’s Mercy Northland
        801 N.W. Barry Road, Kansas City, MO
      3. Children’s Mercy South College Boulevard Clinics
        5520 College Blvd. Suite 130, Overland Park, KS
    • Please specify appointment location preference on the New Patient Appointment Form
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • For questions regarding Downtown or Northland appointments: (816) 234-3380 (press 2 to speak with someone)
    • For questions regarding College Boulevard appointments: (913) 696-5010
    Plastic Surgery Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Plastic Surgery Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Plastic Surgery Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Plastic Surgery Clinic at (816) 234-1666 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776.
    Specialty Form(s) to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Plastic Surgery Clinic: (816) 234-1666 (press 4 to speak with someone)
    For more information see the Plastic and Reconstructive Surgery Section website
    Pulmonology Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Pulmonology Clinic, please complete the New Patient Appointment Form and submit electronically. 
    • The Contact Center will contact the parent to schedule an appointment and will notify the PCP the date/time of the appointment

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Pulmonology Clinic at (816) 983-6490 (press 4 to speak with someone)
    Referral Tips:
    • When completing this form by hand, please also fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776
    • Please fax lab results and/or other test results with this form along with clinic notes describing the patient’s symptoms, to the Contact Center at (816) 855-1776
    • The Pulmonology Clinic has three different locations to serve your patients:
      1. Children’s Mercy Hospital – Monday through Friday
        2401 Gillham Road, Kansas City, MO
      2. Children’s Mercy Northland – Wednesdays and Thursdays
        501 NW Barry Rd, Kansas City , MO
      3. Children’s Mercy South – Tuesdays
        5520 College Blvd. Suite 130, Overland Park, KS
    • Please specify appointment location preference on the New Patient Appointment Form
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in the either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Pulmonology Clinic: (816) 983-6490 (press 4 to speak with someone)
    For more information see the Pulmonary & Sleep Medicine website
    Pulmonology Lab
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Pulmonology Lab for a pulmonary function study, please call (816) 234-3422 to speak with a member of the Pulmonology Lab staff to schedule the appointment

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Pulmonology Lab direct at (816) 234-3422
    Referral Tips:
    • Please fax order and patient demographic information to (816) 983-6626, attention Pulmonology Lab
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in the below department:
    • Pulmonology Lab Staff: (816) 234-3422
    For more information see the Pulmonary & Sleep Medicine website
    Rehabilitation Medicine Clinics
    Botox Clinic
    Referral Process for a NEW PATIENT:
    • Children must be seen in the General Rehab Clinic for evaluation prior to setting up a BOTOX appointment.
    • To refer a new patient to the BOTOX Clinic for evaluation, please complete the Rehabilitation Referral Form and fax to (816) 983-6845. Make sure all areas are completely filled out.
    • The phone triage nurse will contact the parent to schedule an appointment and will notify the PCP of the date and time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • The patient must have been seen in the BOTOX Clinic, within the last year. Call the BOTOX nurse at (816) 234-3778.
    • If the patient has not been seen for more than 1 year, they must be seen by a Rehab provider for a BOTOX re-evaluation prior to scheduling an appointment. Call the phone triage nurse at (816) 234-3970 to schedule an appointment.
    Referral Tips:
    • Children commonly seen in the BOTOX Clinic include those with Cerebral Palsy, Spasticity’s, Diplegia, Quadriplegia, Triplegia, Monoplegia, Dystonia, Idiopathic Toe Walking, Hemiplegia, Contractures, Torticollis, Cervical Dystonia.
    • The Rehabilitation Clinic has two different locations to serve your patients:
      1. Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO – Monday through Friday in the Special Care/Rehab Medicine Clinic.
      2. Children’s Mercy Northland – 501 NW Barry Road, Kansas City, MO on limited Monday's.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral:
    • Please contact the phone triage nurse at (816) 234-3970
    For more information see the Rehabilitation Clinic website
    Brachial Plexus Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Brachial Plexus Clinic for evaluation, please complete the Rehabilitation Referral Form and fax to (816) 346-1372. Make sure all areas are completely filled out.
    • Please fax any physician notes, X-rays, CT’s and MRI’s to (816) 346-1372.
    • The nurse will contact the parent to schedule an appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • The patient must be actively being followed in the Special Care Clinic.
    • The patient must have been seen in the Brachial Plexus Clinic previously.
    • Please have the parents contact Lindsey or Roni at (816) 234-3790.
    Referral Tips:
    • Children commonly seen in the Brachial Plexus Clinic include those with: Brachial Plexus abnormalities.
    • When completing the Rehabilitation Referral Form please include details in the Notes/Special Instructions section regarding:
      1. Which arm (right, left, or both).
      2. Can the child bend their elbow?
      3. Has the child had surgery? If so, who was the surgeon?
    • The Rehabilitation Clinic has two different locations to serve your patients:
      1. Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO is held on the 1st Thursday morning of the month. The clinic is located in the Special Care/Rehab Medicine Clinic.
      2. Children’s Mercy Northland – 501 NW Barry Road, Kansas City, MO is held on the 2nd Thursday of the month, all day.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral:
    • Please contact Lindsey or Roni at (816) 234-3790.
    For more information see the Rehabilitation Clinic website
    EMG (Electromyography) Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the EMG (Electromyography) Clinic for evaluation, please complete the EMG Referral Form and fax to (816) 983-6845. Make sure all areas are completely filled out.
    • The phone triage nurse will contact the parent to schedule an appointment and will notify the PCP of the date and time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • None
    Referral Tips:
    • Children commonly seen in the EMG Clinic include those with nerve and muscle disorders.
    • The EMG Clinic is located at Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO in the Special Care/Rehab Medicine Clinic
    • The Clinic is held on Monday and Tuesday mornings.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral
    • Please contact the phone triage nurse at (816) 234-3970.
    For more information see the Rehabilitation Clinic website
    First Look Clinic
    Referral Process for a NEW PATIENT:
    • The First Look Clinic is a clinic for new patients only. This is the clinic that screens patients and determines which clinic within the Rehab Department, would be appropriate for the child to be scheduled. Also, the First Look Clinic would see a patient if they had not started in any type of therapy to determine their needs.
    • To refer a new patient to the First Look Clinic, please complete the Rehabilitation Referral Form and fax to (816) 983-6845. Make sure all areas are completely filled out.
    • Please fax the face sheet and visit notes to (816) 983-6845
    • Please have the parent/guardian bring the following to the appointment: any previous tests results that have been done including labs, X-rays, CT scans, MRI's, and notes from previous doctor’s visits/work ups.
    • The phone triage nurse will contact the parent to schedule an appointment and will notify the PCP of the date and time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • No follow-up visits for this clinic.
    Referral Tips:
    • Children commonly seen in the First Look Clinic include new patients with any type of physical disability prior to receiving any therapies, Cerebral Palsy, any spasticity concerns, gait concerns, developmental concerns—specifically gross motor/fine motor, low tone concerns.
    • The First Look Clinic is located at Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO.
    • Operates on the 2nd and 4th Wednesday of the month, all day in the Special Care Clinic.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral:
    • Please contact the phone triage nurse at (816) 234-3970
    For more information see the Rehabilitation Clinic website
    Focus Clinic
    Referral Process for a NEW PATIENT:
    • Children commonly seen in the Focus Clinic include those who are already established in one of the Rehab Clinics and who are having a specific problem which can be resolved quickly or needs to be addressed before the next scheduled appointment such as: pain, bracing concerns, or medication concerns.

    Referral Process for a FOLLOW-UP PATIENT:
    • Must have been seen in the Rehabilitation clinic within the past 12 to 18 months.
    • Please have the parents contact the phone triage nurse at (816) 234-3970 to schedule an appointment.
    Referral Tips:
    • The Focus Clinic is located at Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO in the Special Care/Rehab Medicine Clinic.
    • The clinic is held on the 1st and 3rd Friday mornings of the month.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral:
    • Please contact the phone triage nurse at (816) 234-3970
    For more information see the Rehabilitation Clinic website
    Limb Deficiency (Amputation) Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Limb Deficiency Clinic, please complete the Rehabilitation Referral Form and fax to (816) 983-6845. Make sure all areas are completely filled out.
    • Please fax any past clinic notes from referring provider and X-rays to (816) 983-6845.
    • The nurse practitioner will contact the parent to schedule an appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • None
    Referral Tips:
    • Children commonly seen in the Limb Deficiency Clinic include those with: congenital amputations, acquired amputations, limb differences.
    • The Limb Deficiency Clinic is located at Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO in the Special Care/Rehab Medicine Clinic.
    • This clinic is held on the 2nd and 4th Fridays of the month, all day.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral:
    • Please contact the phone triage nurse at (816) 234-3970
    For more information see the Rehabilitation Clinic website
    Mild Traumatic Brain Injury (Concussion) Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Mild Traumatic Brain Injury Clinic, please complete the Rehabilitation Referral Form and fax to (816) 983-6845. Make sure all areas are completely filled out.
    • Please fax any MRI’s, CT’s, previous ImPACT testing results, clinic/visit notes related to this injury, and discharge summary if patient was admitted the hospital to (816) 983-6845.
    • The nurse practitioner will contact the parent to schedule an appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • None
    Referral Tips:
    • Children commonly seen in the Mild Traumatic Brain Injury Clinic include those with: mild traumatic brain injuries, concussions.
    • The Mild Traumatic Brain Injury Clinic is located at Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO in the Special Care/Rehab Medicine Clinic.
    • The clinic is held on Wednesdays.
    • When completing the Rehabilitation Referral Form please include details in the Notes/Special Instructions section regarding:
      1. When the accident occurred.
      2. What happened with the accident.
      3. What symptoms the patient is having.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral:
    • Please contact the phone triage nurse at (816) 234-3970
    For more information see the Rehabilitation Clinic website
    Muscle Nerve (Muscular Dystrophy) Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Muscle Nerve Clinic, please complete the Rehabilitation Referral Form and fax directly to the Muscle Nerve Clinic nurse coordinator at (816) 983-6845.
    • The nurse coordinator will contact the parent to schedule an appointment and will notify the referring provider about the appointment time. If needed, the nurse coordinator may call the referring provider to obtain more information about the child.
    • The referring provider should fax all pertinent medical records to the Rehabilitation Medicine Office at (816) 983-6845, attention Muscle Nerve Clinic nurse coordinator. (For example: general health records, developmental evaluations, lab studies, EMG’s, DNA testing, muscle biopsy, scans of brain/spine, nutritional evaluation, progress notes from physical therapist or occupational therapist, swallow studies, speech evaluations, etc.). The nurse coordinator will make the appointment when these records are received.

    Referral Process for a FOLLOW-UP PATIENT:
    • None
    Referral Tips:
    • Children commonly evaluated and followed in the Muscle Nerve Clinic include those with: hypotonia, proximal muscle weakness, developmental delay, toe walking without central nervous system etiology, Duchenne’s/Becker’s muscular dystrophies, other muscular dystrophy disorders, myotonic disorders/periodic paralyses, metabolic myopathies, congenital myopathies, inflammatory myopathies, spinal muscular atrophy, chronic inflammatory demyelinating neuropathy and Guillain-Barre Syndrome, neuromuscular transmission defects, amyoplasia congenital/arthrogryposis.
    • Some symptoms you may see in the patient: high CK levels (If high LFT’s, check CK), calf hypertrophy, motor delay, speech delay, weakness, fatigue, “walks funny,” family history of muscle/nerve disease.
    • The Muscle Nerve Team of specialists includes: physiatrists, nurse practitioners, physical therapist, occupational therapist, respiratory therapist, nutritionist, social worker, genetic counselor, and palliative care nurses.
    • The Muscle Nerve Clinic is located at Children’s Mercy Hospitals and Clinics at 2401 Gillham Road, Kansas City, MO 64108 in the Special Care/Rehab Medicine Clinic.
    • The Muscle Nerve Clinic Operates on the 1st, 3rd, and 5th Monday afternoons of the month.
    • Clinic appointments are usually about 75 minutes in length.
    • Parents should complete a new patient health history form before the new patient appointment. The nurse coordinator will mail the form to the parent when the new patient appointment is made.
    • The nurse coordinator will arrange follow-up appointments after a child has been evaluated in one of the Rehabilitation Clinics or the Muscle Nerve Clinic.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral:
    • Please contact the Muscle Nerve Clinic Nurse Coordinator or the Rehabilitation Medicine triage nurse at (816) 234-3970.
    For more information see the Rehabilitation Clinic website
    Rehabilitation Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Muscle Nerve Clinic, please complete the Rehabilitation Referral Form and fax to (816) 983-6845. Make sure all areas are completely filled out.
    • Please also fax face sheet, visit notes, and therapy notes to (816) 983-6845.
    • The phone triage nurse will contact the parent to schedule an appointment and will notify the PCP of the date and time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • The patient must have been seen in the Rehabilitation Clinic within the last 2 years.
    • Please have the parents contact the Rehabilitation Clinic at (816) 234-3970 to schedule an appointment.
    Referral Tips:
    • Children commonly seen in the Rehabilitation Clinic include those with: physical disabilities with therapies in place – either previous or current, Cerebral Palsy, Spasticity’s, gait concerns, developmental concerns, low tone concerns.
    • The Rehabilitation Clinic has two different locations to serve your patients:
      1. Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO on the 2nd and 4th Monday afternoons; all day on Tuesdays; the 1st, 2nd and 4th Thursday afternoons; and the 1st and 3rd Friday mornings. The clinic is held in the Special Care/Rehab Medicine Clinic.
      2. Children’s Mercy Northland – 501 NW Barry Road, Kansas City, MO on the 1st and 3rd Thursdays, all day.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral:
    • Please contact the phone triage nurse at (816) 234-3970
    For more information see the Rehabilitation Clinic website
    Seating (Wheelchair) Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Seating Clinic, please complete the New Patient Referral Form and submit electronically.
    • In the reason for referral section please indicate:
      1. The family’s preference for a vendor or write “No Vendor Preference” if they do not have a specific vendor they prefer to use.
      2. Appointment location preference.
    • Choose PT/OT and put in “Seating Clinic Evaluation” as reason for referral.
    • The PT/OT Department will contact the parent to schedule an appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • None
    Referral Tips:
    • Children commonly seen in the Seating Clinic include those with wheelchairs or other specialty seating devices.
    • Please see the Wheelchair/Seating Clinic graph decision tree to determine if the child should be seen in the seating clinic.
    • The Rehabilitation Clinic has three different locations to serve your patients:
      1. Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO on the 1st Tuesday afternoon and the 3rd Thursday afternoon of the month in the Special Care/Rehab Medicine Clinic.
      2. Children’s Mercy Northland – 501 NW Barry Road, Kansas City, MO on the 4th Monday afternoon of the month.
      3. Children’s Mercy South – 5520 College Blvd., Suite 130, Overland Park, KS on the 2nd Tuesday afternoon of the month.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral:
    • Please contact the PT/OT department at (816) 234-3380
    For more information see the Rehabilitation Clinic website
    Spasticity (Cerebral Palsy) Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Spasticity Clinic, please complete the Spasticity Patient Intake Form and fax to (816) 346-1372 attention Lindsey. Make sure all areas are filled out completely.
    • The Spasticity Nurse will contact the parent to schedule an appointment and will notify the PCP of the date and time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • The patient must have been seen in the Spasticity Clinic previously.
    • Please have the parents contact the Spasticity Clinic nurse at (816) 234-3790, and ask to speak to Lindsey to schedule an appointment.
    Referral Tips:
    • Children commonly seen in the Spasticity Clinic include those with Spasticity who have been seen in the Rehab/Ortho Clinic previously and are seeking evaluation for Intrathecal Baclofen Pump; Selective Dorsal Rhizotomy Surgery; or any other type of orthopedic rehabilitation intervention for the management of spasticity.
    • The Spasticity Clinic is located at Children’s Mercy Northland, 501 NW Barry Road, Kansas City, MO.
    • The clinic is held on the first Thursday morning of the every month.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral:
    • Please contact Lindsey at (816) 234-3790
    For more information see the Rehabilitation Clinic website
    Spinal Defects (Spina Bifida) Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Rehabilitation Clinic, please complete the Rehabilitation Referral Form and fax to (816) - 983-6845. Make sure all areas are completely filled out.
    • Please fax any previous clinical records, lab results, radiology reports to (816) 983-6845.
    • The nurse will contact the parent to schedule an appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • None
    Referral Tips:
    • Children commonly seen in the Spinal Defects Clinic include those with: Spina Bifida, spinal cord trauma, spinal cord tumor, tethered cord, caudal regression, lipomeningocele, those requiring multiple disciplines.
    • Children NOT seen in the Spinal Defects Clinic include those with: sacral dimples, dermal sinus – these patients need to be evaluated by Neurosurgery prior to being seen in the Spinal Defects Clinic.
    • The Spinal Defects Clinic is located at Children’s Mercy Hospitals and Clinics – 2401 Gillham Road, Kansas City, MO in the Special Care/Rehab Medicine Clinic.
    • The Spinal Defects Clinic is held on the 1st, 3rd, and 5th Wednesday mornings of the month.
    • Please bring all x-ray film CD’s with you to the first appointment.
    • Bring all adaptive equipment that the child uses to the appointment.
    • This is a multidisciplinary clinic and each appointment lasts from 3 to 4 hours.
    • You may bring food, snacks, etc. with you to this appointment as it is a long visit.
    • Contact the social services department if you need Ronald McDonald house lodging the night before the appointment.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral:
    • Please contact the Spinal Defects nurse at (816) 234-3005
    For more information see the Rehabilitation Clinic website
    Torticollis Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Torticollis Clinic, please have the physical therapist call (816) 234-3970 or complete the Rehabilitation Referral Form and fax to (816) 983-6845, to schedule an appointment.
    • The physical therapist should fax face sheet and therapy notes to (816) 983-6845.
    • The scheduling nurse will contact both the physical therapist and the parent with appointment information.
    • Please continue physical therapy until seen in the Torticollis Clinic.

    Referral Process for a FOLLOW-UP PATIENT:
    • The patient must have been seen in the Torticollis clinic previously.
    • Please have the parents contact the phone triage nurse at (816) 234-3970 to schedule an appointment.
    Referral Tips:
    • The purpose of this clinic is to evaluate infants with the diagnosis of unresolved Torticollis with the intent of providing BOTOX treatment to assist in the resolution of the condition.
    • Children commonly seen in the Torticollis Clinic include those with:
      • Confirmed diagnosis of Torticollis – this is not a diagnostic clinic. Torticollis should have already been diagnosed by the PCP prior to being seen in this clinic.
      • Between the ages of 6 months and 16 months when referred to the Torticollis clinic. We do not accept referrals for babies less than 6 months of age, infants over the age of 18 months, or infants who have not had physical therapy yet.
      • Patients over the age of 18 months need to be seen in the Plastic Surgery clinic.
      • Must currently be in physical therapy – 6 months of treatment is preferred as this is a reasonable length of time for resolution of symptoms. Patients who have received at least 3-4 months of therapy will be considered if the physical therapist evaluates them to be non-responsive and are not showing month-to-month gains.
      • If the infant has a known abnormal C-Spine film, they need to be seen in the Orthopaedic clinic instead of the Torticollis clinic. It is for this reason that we would recommend a child/infant who is not responding and progressing in therapy to have soft tissue x-rays of c-spine to rule out any type of congenital malformation.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral:
    • Please contact the phone triage nurse at (816) 234-3970
    • Parents and medical team members may feel free to contact the Rehabilitation Medicine office at (816) 234-3970 with any questions or concerns.
    For more information see the Rehabilitation Clinic website
    Rheumatology Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Rheumatology Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Rheumatology Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Rheumatology Clinic direct at (816) 234-1666 (press 4 to speak with someone)
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776
    • You must press PRINT to keep a copy of the New Patient Appointment Form
    • Please fax lab results and/or other test results with this form, if available, to the Contact Center at (816) 855-1776
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Rheumatology Clinic: (816) 234-3686
    For more information see the Rheumatology Section website
    SCAN Clinic
    Referral Process for a NEW PATIENT/FOLLOW-UP PATIENT:
    • To refer a new or follow-up patient to the SCAN (Safety, Care and Nurturing) Clinic, please contact the SCAN Clinic directly at (816) 234-3424 or (816) 234-1633 to speak with a SCAN Clinic medical provider.
    • SCAN Clinic telephones are answered Monday - Friday between 8:00AM and 9:00PM.
    Referral Tips:
    • Any information regarding the interventions you have attempted is appreciated.
    • Please feel free to offer any insight you have into the patient/family.
    • Fax pertinent patient records to the SCAN Clinic at (816) 855-1948.
    • Please be prepared to provide the following information regarding the referral:
      1. Patient demographic information
        • Name
        • Date of Birth
        • Parent/Guardian’s Name
        • Patient’s address
        • Patient’s telephone number
      2. Contact information for patient’s current caregiver
        • Name
        • Relationship to patient
        • Address
        • Telephone numbers
      3. Reason for referral (concerns of physical abuse, sexual abuse, etc.)
        • Who is the alleged offender? (i.e. mother, father, unknown)
        • When was the last physical contact between this person and the patient?
      4. Does the patient currently have any physical symptoms?
        • Pain, bleeding, discharge, bruising, wounds
      5. Have these concerns been reported to the appropriate Child Protection Services Agency? (i.e. Hotline to MO Children’s Division or Kansas SRS)
        • If so, which agency?
      6. Have these concerns been reported to the appropriate law enforcement agency?
        • If so, which agency?
    Specialty Form(s) to be provided to the patient’s family prior to a scheduled appointment will be mailed to the family’s address you provide:
    For questions about a referral:
    • Please contact the SCAN Clinic directly at (816) 234-3424 or (816) 234-1633.
    For more information see the SCAN Section website
    Sleep Disorders Program
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Sleep Disorders Clinic, please complete the New Patient Appointment Form and submit electronically. 
    • The Contact Center will contact the parent to schedule an appointment and will also notify the PCP the date/time of the appointment.
    • Please specify appointment location preference on the New Patient appointment form.
    • All patients must be evaluated by a CMH Sleep physician before a sleep study can be scheduled.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Sleep Disorders Clinic direct at (816) 983-6355 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please also fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • Please fax lab results and/or other test results with this form along with clinic notes that describe the patient’s sleep problem, to the Contact Center at (816) 855-1776.
    • The Sleep Clinic has three different locations to serve you:
      1. Children’s Mercy Hospital – On Monday and Thursday afternoons
        2401 Gillham Road, Kansas City, MO
      2. Children’s Mercy Northland – On Tuesdays
        501 NW Barry Rd, Kansas City , MO
      3. Children’s Mercy South – On Mondays and Wednesdays
        5520 College Blvd. Suite 130, Overland Park, KS
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Sleep Disorders Clinic: 8(816) 983-6355 (press 4 to speak with someone)
    For more information see the Comprehensive Sleep Disorders Program website
    Special Care (Neonatology) Clinic
    Special Care Clinic provides care for graduates of Neonatal Intensive Care Units from birth to age 2 who have ongoing medical needs including:
    • History of prematurity
    • Chronic lung disease
    • Durable medical equipment – apnea monitors, oxygen, gastrostomy tubes, etc.
    • Feeding difficulties
    • High risk medications
    • Developmental challenges
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Special Care Clinic, please complete the Special Care Patient Appointment Form and fax to the Special Care Clinic at (816) 234-3590.
    • Please fax a discharge summary from the birth facility to (816) 234-3590.
    • The Special Care Clinic Phone Triage nurse will contact the referring provider to schedule an appointment.

    Referral Process for a FOLLOW-UP PATIENT (must be actively followed in the Special Care Clinic):
    • Must have been seen in the Special Care clinic previously.
    • To refer a follow-up patient, please have the parents contact the Special Care Clinic at (816) 234-3791 (press 4 to speak with someone) to schedule an appointment.
    Referral Tips:
    • If completing the Specialty Care Patient Appointment Form by hand, please also fax a copy of the face sheet/demographic sheet to (816) 234-3590.
    • The Special Care clinic is located at Children's Mercy Hospitals and Clinics – Monday through Friday – 2401 Gillham Road, Kansas City, MO.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    For questions about a referral, contact the Special Care Clinic Phone Triage Nurse at:
    • (816) 234-3595 (press 4 to speak with someone)
    For more information see the Special Care Clinic website
    Sports Medicine Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Sports Medicine Clinic, please complete the New Patient Appointment Form and press SUBMIT and the form will be faxed to the Contact Center at Children's Mercy Hospital
    • The Orthopaedic Clinic staff will contact the parent to schedule the appointment and will also notify the PCP the date/time of the appointment.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Sports Medicine Clinic directly, at (816) 701-HURT (4878) (press 1 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • If this referral is a result of an injury, please include the date the injury happened.
    • Please fax x-ray/MRI/CT reports with this form, if available, to the Contact Center at (816) 855-1776.
    • If the tests were done at Children's Mercy Hospital, do not fax the results. Write a note on the referral form and we will find the results in the patient’s medical record at Children's Mercy Hospital.
    • Family needs to bring the actual films to the appointment.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Sports Medicine Clinic: (816) 701-HURT (4878) (press 1 to speak with someone)
    For more information see the Sports Medicine website
    Surgery Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Surgery Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Contact Center or the Surgery Clinic staff will contact the parent to schedule the appointment

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Surgery Clinic direct at (816) 234-3199 (press 4 to speak with someone)
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Surgery Clinic: (816) 234-3199
    For more information see the Surgery Department website
    Teen Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Teen Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Teen Clinic staff will contact the parent to schedule an appointment for the patient and will also notify the PCP the date/time of the appointment.
    • For complicated issues (chronic pain, behavioral problems, social issues, etc.) a provider-to-provider contact is often very helpful; please provide contact information and the best time to call on the referral form.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Teen Clinic directly, at (816) 960-3050 (press 4 to speak with someone).
    Referral Tips:
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • If previous lab/radiologic studies or growth charts have been done, please include results and a brief summary on the referral form.
    • For reproductive health needs: generally, no previous records are necessary.
    • For gynecologic issues: any previous lab results or treatments should be included.
    • For complex patients: please include any previous notes or treatments.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • none
    For questions about a referral, contact staff in the below department:
    • Teen Clinic Triage Nurse: (816) 960-3050 (press 4 to speak with someone)
    For more information see the Adolescent Medicine Section website
    Urology Clinic
    Referral Process for a NEW PATIENT:
    • To refer a new patient to the Urology Clinic, please complete the New Patient Appointment Form and submit electronically.
    • The Contact Center or the Urology Clinic staff will contact the parent to schedule the appointment

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact the Urology Clinic direct at (816) 234-3199 (press 4 to speak with someone)
    Referral Tips: 
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • Urology Clinic: (816) 234-3199 (press 4 to speak with a live person)
    For more information see the Urologic Surgery website
    Weight Management Clinic
    PHIT Kids Weight Management Clinic
    In the Promoting Health In Teens and Kids (PHIT Kids) Weight Management Clinic, we promote family-based healthy lifestyle changes. Patients will be evaluated by a pediatric medical provider and may be also seen by several other health professionals, including a dietitian, social worker, physical therapist and psychologist. The initial evaluation will occur over 1 or 2 visits.
    Referral Process for a NEW PATIENT:
    • Please ask the parent to call (816) 960-2852 to schedule an appointment. Please print an instruction sheet (en espanol) to give to the parent or guardian. The clinic will notify the PCP if the parent does not contact the clinic for an appointment within 30 days of receiving the referral.
    • To refer a new patient to the PHIT Kids Weight Management Clinic, please also complete the New Patient Appointment Form to submit electronically. You must press PRINT to keep a copy of this form) BMI requirements are 95% or greater. By submitting this form, this will serve as a referral, not a request for an appointment.
    • We recommend the following labs prior to referral:
      1. Hemoglobin A1c
      2. Lipid Profile
      3. Liver Function Tests
      4. Basic Metabolic Panel
    • If you choose to order these labs, please fax results to the Contact Center at (816) 855-1776. Ordering providers are asked to review labs results with parents.
    • Please also fax a growth chart with past heights, weights and BMIs plotted.

    Referral Process for a FOLLOW-UP PATIENT:
    • To refer a follow-up patient, please have the parents contact contact the PHIT Kids Weight Management Clinic direct at (816) 960-2852.
    Referral Tips:
    • For the most meaningful initial appointment, referring providers may order the recommended lab tests mentioned above. Please fax results to the Contact Center at (816) 855-1776. Ordering providers are asked to review lab results with parents.
    • When completing this form by hand, please fax a copy of the face sheet/demographic sheet to the Contact Center at (816) 855-1776.
    • You must press PRINT to keep a copy of the New Patient Appointment Form.
    • Please fax lab results and growth charts with this form, if available, to the Contact Center at (816) 855-1776.
    Please review the following table and consider referring your patient to a different or additional clinic if your patient meets any of the parameters.
     

    Alert: If you suspect a new onset of Type 1 or Type 2 diabetes call 1-800-GO-Mercy ((800) 466-3729) at Children’s Mercy Hospital and ask to speak to the endocrinologist on call. The endocrinologist on call is available 24/7. Contact them directly if you suspect the child needs to be seen urgently.

    Endocrine Clinic

    Cardiology Clinic
    Preventive Cardiology Clinic
    • HbA1c > 6.0%
    • Fasting Glucose is greater than 100 mg/dL
    • Random glucose is
    • greater than 140mg/dL
    • Precocious puberty in male or female
    • Masculinization in female
    • Obesity and growth failure
    		 One or more of the following:
    • Total Cholesterol > 220 mg/dL
    • LDL-cholesterol > 130 mg/dL
    • HDL-cholesterol < 35 mg/dL
    • Triglycerides > 150 mg/dL
    • First degree relative who has had premature heart disease/died/or has dyslipidemia


    Kidney Center
    Hypertension Clinic

    Adolescent/Teen Clinic
    3 documented blood pressure readings equal to or greater than 120/80 or equal to or greater than the 90th percentile for age, gender and height percentile Polycystic Ovary Disease (PCOS)
    • Exam signs of hyperandrogenism
    • Amenorrhea
    • No obvious endocrinopathy


    Special Needs Weight Management Clinic
    Special Needs Weight Management Clinic is available for “established” CMH patients with diagnosis of any of the following conditions and a BMI greater than or equal to 95th%
    • Autism Spectrum Disorders
    • Down Syndrome
    • Developmental Disabilities
    Patients must be referred by a CMH provider:
    • Ask parent to call (816) 234-9231 to schedule an appointment
    • Submit a referral for Special Needs Weight Management Clinic using the Provider Portal.
    Non-CMH Providers should:
    • Refer patients to PHIT Kids Weight Management Clinic using the Provider Portal.
    • Indicate that patient is a Special Needs patient.
    • Instruct parent to call (816) 960-2852 to schedule an appointment.
    For more information on the Specialty Clinics above please access the Provider Portal.
    Specialty Form(s): to complete for Pre-Visit Appointment:
    • None
    For questions about a referral, contact staff in either of the below departments:
    • Contact Center: (816) 234-3700 or (800) 800-7300
    • PHIT Kids Weight Management Clinic: (816) 960-2852
    For more information see the PHIT Kids Weight Management Program website

CMH Employees