Referral Information

Specialty --None--Adolescent Specialty Allergy & Immunology Burn unit Cardiology Comprehensive Colorectal Center Dermatology Developmental & Behavioral Sciences Down Syndrome Ear, Nose & Throat Eating Disorders Endocrine Environmental Health Fetal Health Center Gender Pathway Services (GPS) Genetics GI Feeding Clinic GI General Clinic GI Hepatology Clinic GOLDILOKs Gynecology Hearing & Speech Hematology & Oncology Infectious Disease Lab Neonatal Follow-Up Nephrology Neurology Neurophysiology Lab Neurosurgery Nutrition Ophthalmology Orthopedic Surgery Pain Management Palliative Care PCC- Newborn Circumcision Pectus Center Physical & Occupational Therapy Plastic Surgery Pulmonology Rehabilitative Medicine Rheumatology Safety, Care & Nurturing(SCAN) School Asthma Sleep Medicine Sports Medicine Surgery Tic & Tourette Urology Weight Management

Reasons for Consultation --None--

Selected Specialty and Diagnosis

Specialty	Reasons for Consultation	Patient Symptoms	Action

*Is a hearing test needed?--None--Yes No

*Is Second Opinion?--None--Yes No

*Is this patient medically complex?--None--Yes No

*Preferred Appointment Timeframe--None--First Available (varies per clinic) Seven Days Two Weeks One Month

*Preferred Appointment Location--None--Kansas City, MO Independence, MO Joplin, MO North Kansas City, MO Overland Park, KS St. Joseph, MO Topeka Wichita, KS Junction City, KS KU Campus Garden City Great Bend Olathe, KS Telemedicine Patient Home Telemedicine Facilitated Wichita Telemedicine Facilitated St. Joseph Telemedicine Facilitated Joplin Telemedicine Facilitated Junction City Foreign Language Academy Whittier Elementary

*Co-Morbidities--None--Cancer Coginitive Delays Cystic Fibrosis Degenertive Disc Disease Disc Herniation Disordered Eating Ehlers Danlos Syndrome Endometriosis Epidermolysis Bullosa Juvenile Arthritis Lupus Mis-C Post Covid Neurodegenrative Disorders Osteogenesis Imperfecta Post-Laminectomy Syndrome Post-Thoracotomy Syndrome Sickle Cell Spina Bifida Spinal Stenosis Tube Feed due to pain Unstable Hip Dysplasia Other N/A

*Ambulatory Status--None--Weight bearing Boot/brace/sling Cane/crutches/walker Wheel chair Other

*Are you submitting patient's most recent labs?--None--Yes No

*Are you submitting patient's most recent imaging?--None--Yes No

*Are you submitting your last clinic note?--None--Yes No

Lab/Images Completed?

Lab/Images Location

*Has the patient been diagnosed by their primary care provider or a mental health professional with obsessive-compulsive disorder?--None--Yes No

*Does the patient have tics? Tics are involuntary, sudden, and non-rhythmic movements or vocalizations such as excessive blinking, facial grimacing, shoulder shrugging, sniffing, or grunting.--None--Yes No

*Has the patient had evidence of worsened OCD or tics in the setting of strep throat diagnosed from a rapid strep test or throat culture?--None--Yes No

*Has the patient had evidence of worsened OCD or tics within 3 months of a positive antistreptolysin O titer (ASO) or within 6 months of a positive Anti-DNase titer?--None--Yes No

Patient must have an official diagnosis of OCD/tics in order to be referred/scheduled

Patient must have a confirmed positive strep workup in order to be referred/scheduled

Weight Management

*Does the patient have a special healthcare need such as Autism Spectrum Disorder, Down Syndrome, a genetic cause of obesity such as Prader-Willi, or a physical or developmental disability?--None--Yes No

*Have you discussed bariatric surgery to help with weight loss for this patient?--None--Yes No

*What is the child’s current BMI percentile?

*Can the child participate in regular education classroom as required?--None--Yes No

Referring Provider

*Practice Name   (If your practice is not listed, type Unknown)

Clinic Not Found.

Provider

Provider Not Found.

Unknown Provider

Please only select Unknown Provider if your name does not appear in the above Provider drop down. Name, Credentials, Office Phone and Fax are only required in case Unknown Provider is checked.

*Name

*Credentials

*Office Phone   (Enter Back Office Phone Number if available)

*Office Fax

I acknowledge the above represents my electronic signature.

Primary Care Provider

Primary Care Provider same as Referring Provider

Name

Credentials

Patient Information

*First Name

*Last Name

*Date of Birth

Patient age needs to be above 6 years in order to continue

The GI Feeding Clinic is currently ONLY ACCEPTING REFERRALS FOR PATIENTS UNDER THE AGE OF 6 YEARS OLD. If patient is 6 years old or older, please place referral for General GI.

*Gender--None--Female Male Unknown Indeterminate Unspecified

Height (In Inches)

Weight (In Lbs)

*Preferred Phone

Parent/Guardian Information

*First Name

*Last Name

*Relationship--None--Guardian Mother Father

*Preferred Language--None--Amharic Arabic Bajuni Bengali Bosnian Bulgarian Bunjabi Burmese Cambodian Cantonese Chin Chinese Chuukese Cronk/Liberian Dinka English Ethiopian Falam Chin Farsi Filipino French German Haitian Creole Hakha Chin Hmong Indonesian Japanese Karen Kirin Korean Kurdish Lautu Chin Liberian Loatian Madi Mai Mai Mandarin Micronesian Mongolian Nigerian Pigin Nuer Other Persian Pigin English Portugese Punjabi Respondent N/A Romanian Russian Samoan Serbian Serbo-Croatian Sign Language Somali Spanish Sudanese Swahili Tagalog Ukranian Urdu Vietnamese SP

Preferred Email Address

Insurance Information

In compliance with the No Surprise Billing Act , Children’s Mercy requires the referring providers to enter their patient’s full insurance information at the time of the referral. Missing or inaccurate information could lead to a delay in your patient’s appointment being scheduled Please ensure to upload a copy of the patient’s front and back of their insurance card with the completion of this form.

*Primary Insurance --None-- AETNA AETNA BENEFIT PLANNERS Aetna Care Link (ACA Exchange) Aetna Connected AETNA HCA SMART CARE Aetna I-35 Preferred AETNA MAIL HANDLERS BENEFITS AETNA SRC AETNA WAUSAU BENEFITS ALL SAVERS AMBETTER FOR HOME STATE HEALTH PLAN Out of Network AMBETTER FOR SUNFLOWER HEALTH PLAN Out of Network AMERICAN HEALTHCARE ALLIANCE AMERICAN MEDICAL SECURITY LEGACY Ascension Out of Network Aspen Short Term Medical BCBS Kansas BlueChoice (ACA Exchange) BEECHSTREET BEECHSTREET CERNER BEHAVIORAL CIGNA BEHAVIORAL CORPHEALTH INC BEHAVIORAL HEALTH OTHER BEHAVIORAL INTERFACE EAP BEHAVIORAL KS MEDICAID CENPATICO BEHAVIORAL KS MEDICAID UBH BEHAVIORAL MHNET COVENTRY BEHAVIORAL MO MEDICAID CENPATICO BEHAVIORAL MO MEDICAID MHNET BEHAVIORAL MO MEDICAID UBH BEHAVIORAL NEW DIRECTIONS BEHAVIORAL OPTUM BEHAVIORAL VALUE OPTIONS Bind On-Demand Health Insurance-Out of Network BLUE CARE HMO BLUE CHOICE HMO Blue Cross Blue Shield BLUE ACCESS Out of Network Blue Cross Blue Shield BLUE SELECT Out of Network Blue Cross Blue Shield Federal Employee Program Blue Cross Blue Shield of Kansas Blue Cross Blue Shield OTHER PREFERRED CARE Blue Cross Blue Shield Pathway/Pathway X Out of Network Blue Cross Blue Shield PREF CARE BLUE EXCHANGE Blue Cross Blue Shield PREFERRED CARE BLUE BLUE SELECT Blue Select Plus BlueKC High Performance Network CAREMARK 340B CARPENTERS MERITAIN PLAN CENTURY HEALTH SOLUTIONS CERNER HEALTH PLAN SERVICES FREEDOM NETWORK CHAMPVA CHRISTIAN HEALTH AID CIGNA CIGNA CMH EMPLOYEE PLAN CIGNA CONNECT EXCHANGE CIGNA GREAT WEST CIGNA HEALTH PARTNERS Cigna Health Partners Unity Point Out of Network Cigna Local Plus Cigna Simple Choice (ACA Exchange) Cigna Sure Fit COMMUNITY CARE NETWORK CORESOURCE TRUSTMARK Cost Share/ Ministry Sharing Group (Cost Share Self-Pay) COVENTRY COVENTRY NATIONAL Cox Health EPO Exchange-Out of Network Cox Health Plans Utilizing First Health Network Custom Network Plan - Administered by UHC-Out of Network DENTAL DELTA DENTAL DENTAL INSURANCE DENTAL INSURANCE SECONDARY DENTAL KS MEDICAID DHW DENTAL KS MEDICAID SCION DENTAL METLIFE DENTAL DENTAL MO MEDICAID DENTAL MO MEDICAID DENTAQUEST DENTAL MO MEDICAID DHW DENTAL MO UNITED COMMUNITY PLAN DENTAL PREFERRED CARE DENTAL TRICARE FIRST HEALTH FIRST STEPS FMH BENEFITS FREEDOM NETWORK FREEDOM NETWORK HEALTHLINK FREEDOM NETWORK SELECT GEHA Health Choice Oklahoma-Out of Network Health Midwest Comprehensive Care (HMCC) Well Care HEALTH PARTNERS OF KANSAS HEALTHLINK HealthPartners at UnityPoint Health- Out of Network HealthSCOPE Benefits Out of Network Healthscope Mercy Arkansas HUMANA HUMANA EXCHANGE INTERNATIONAL PATIENT COMMERCIAL INSURANCE PLAN INTERNATIONAL PATIENT GOVERNMENT INSURANCE PLAN INTERNATIONAL PATIENT SELF PAY Kaiser Permanente Southern CA Out of Network KS MEDICAID KS MEDICAID AETNA BETTER HEALTH KS MEDICAID AETNA BETTER HEALTH PCN KS MEDICAID SUNFLOWER HEALTH PLAN KS MEDICAID UNITED HEALTHCARE COMMUNITY PLAN KS MEDICAID UNITED HEALTHCARE COMMUNITY PLAN PCN KS SPECIAL HEALTH CARE NEEDS LifeShield Short Term Medical Medica Connect (ACA Exchange/Using ProviDRs Care Network) MEDICA United Health Care Medica with MU Health Care (ACA Marketplace/Referral Required) Medica- Balance by Medica (ACA Exchange) Out of Network Medica- Select by Medica (ACA Exchange) Medicaid Arkansas - Empower PASSE Out of Network Medicaid Arkansas - Summit PASSE Out of Network Medicaid Arkansas - Total Care PASSE Out of Network Medicaid Arkansas (Non PASSE Plans) Medicaid Arkansas Care Sources PASSE Out of Network Medicaid Colorado Out of Network Medicaid Illinois Out of Network Medicaid Iowa Out of Network Medicaid Out of State Out of Network Medicaid Texas Out of Network MEDICARE ADVANTAGE MEDICARE PART A MEDICARE PART B MEDPAY Mercy Anthem Alliance EPO (Anthem BCBS) -Out of Network MERCY HEALTH PLANS MO MEDICAID MO MEDICAID Healthy Blue MO MEDICAID Healthy Blue PCN MO MEDICAID HOME STATE HEALTH PLAN MO MEDICAID UNITED COMMUNITY PLAN MO MEDICAID UNITED COMMUNITY PLAN PCN MO SPECIAL HEALTH CARE NEEDS MULTIPLAN OKLAHOMA MEDICAID (Referral Required) Oscar Health Out of Network OTHER COMMERCIAL INSURANCE PHCS PHCS Limited Benefit Plan-Out of Network PHCS Practitioners Only - Out of Network Preferred CommunityChoice Out of Network PREFERRED HEALTH PROFESSNALS Prime Health Services (PHS) Out of Network Prime Healthcare (Anthem Blue Cross) (Approval Needed) QUIK TRIP PHCS SELF PAY/NO INSURANCE ST JOHN'S HEALTH PLAN TRICARE (Referral Needed) UMR1 United Health Care CHOICE PLUS DEFINITY United Health Care GOLDEN RULE United Health Care NAVIGATE United Health Care – Core Essential UNITED HEALTHCARE UNITED HEALTHCARE CHOICE United Healthcare through ACA Exchange Out of Network United Healthcare- Custom Network Plan Out of Network United Healthcare- Deer Premier Out of Network United Healthcare- Surest Out of Network US Health and Life (utilizing Ascension) Out of Network USA MANAGED CARE ORG VISION KS MEDICAID MARCH VISION- OUT OF NETWORK VISION KS MEDICAID OPTICARE/ENVOLVE VISION VISION KS MEDICAID SKYGEN USA VISION MO MEDICAID MARCH VISION Out of Network VISION MO MEDICAID OPTICARE/ENVOLVE VISION VISION VSP VISION VSP ACCESS VISION VSP ACCESS INDEMNITY Walmart/Mercy: Arkansas Local Plan/SW MO Local Plan Out of Network WPPA PPO WPPA ProviDRs Care Employer Network Design- City of Pittsburg Out of Network

Name of Insurance Plan

***Please note, your patient has an insurance plan that does not participate with Children’s Mercy and is out of network. Without pre-approval to be seen at an out of network facility, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for "What if I have an Out of Network Plan" to avoid scheduling delays and reduce surprise financial costs to the family.

***Please note, your patient has an insurance plan that requires an approved referral in order to be seen outside of the MU Health Care system. Without a pre-approved referral, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for to obtain a referral from the plan and enter the referral number below.

***Please note, your patient has an insurance plan that requires an approved referral from Oklahoma Medicaid in order to be seen outside of the state of Oklahoma. Without a pre-approved referral, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for to obtain a referral from Oklahoma Medicaid and enter the referral number below.

***Please note, your patient has an insurance plan that does not cover any services performed in an outpatient hospital setting. This specific plan will only cover office visits with an physican or nurse practitioner. Without pre-approval to have services outside of an office visit, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for "What if I have an Out of Network Plan" to avoid scheduling delays and reduce surprise financial costs to the family.

***Due to the No Surprise Billing Act, patients who are un-insured are required to receive a good faith cost estimate within 3 days of being scheduled. Patients who are un-insured will be placed on a request list to ensure the patient can be provided with the required information. Patients who are un-insured should speak to a Children’s Mercy Financial Counselor to get help covering their cost of care. To avoid your patients experiencing any further scheduling delays and higher out of pocket balances, please refer your patient to contact the Financial Counseling process here

***Please note, your patient has an insurance plan that may require an approved referral from the patient's primary care provider/manager. Some Tricare plans require a referral in order to be seen with a specialist that is not located at military treatment facility. Without a pre-approved referral, your patient may experience scheduling delays or higher out of pocket balances. If required, please ensure you and your patient have followed the steps for to obtain a referral on the Tricare website and enter the referral number below.

***Please note, your patient has an insurance plan that does not cover any services performed in an outpatient hospital setting. (Examples: Labs, Imaging, Procedures, Medications, or any services outside of professional charges for an office visit would not be covered.) This specific plan will only cover an office visit with an physican or nurse practitioner at Children's Mercy. Without pre-approval, your patient may experience scheduling delays or higher out of pocket balances. Please ensure you and your patient have followed the steps for "What if I have an Out of Network Plan" to avoid scheduling delays and reduce surprise financial costs to the family.

***Due to the No Surprise Billing Act, patients who have a Cost Sharing plan are defined as un-insured and are required to receive a good faith cost estimate within 3 days of being scheduled. Patients who are un-insured will be placed on a request list to ensure the patient can be provided with the required information. Patients who are un-insured should speak to a Children’s Mercy Financial Counselor to get help covering their cost of care. To avoid your patients experiencing any further scheduling delays and higher out of pocket balances, please refer your patient to contact the Financial Counseling process here

***Due to the No Surprise Billing Act, patients who have a Short Term Medical plan are defined as un-insured and are required to receive a good faith cost estimate within 3 days of being scheduled. Patients who are un-insured will be placed on a request list to ensure the patient can be provided with the required information. Patients who are un-insured should speak to a Children’s Mercy Financial Counselor to get help covering their cost of care. To avoid your patients experiencing any further scheduling delays and higher out of pocket balances, please refer your patient to contact the Financial Counseling process here

***Due to the No Surprise Billing Act, patients who have a Limited plan are defined as un-insured and are required to receive a good faith cost estimate within 3 days of being scheduled. Patients who are un-insured will be placed on a request list to ensure the patient can be provided with the required information. Patients who are un-insured should speak to a Children’s Mercy Financial Counselor to get help covering their cost of care. To avoid your patients experiencing any further scheduling delays and higher out of pocket balances, please refer your patient to contact the Financial Counseling process here

***Please note, your patient has an insurance plan that deems Children’s Mercy as a Tier 2 provider which will result in higher out of pocket costs. Please coordinate with your patient’s family to ensure any additional approvals are obtained prior to the service to ensure their services at a Tier 1 benefit level to lower their out of pocket costs.

*Referral Approval Status--None--Approved Denied

*Referral Approval Number

*Tricare Plan Type--None--Tricare Prime Tricare Other Plan

*Referral Approval Type--None--Evaluate Only ( 2 office visits only) Evaluate and Treat (6 office visits and any necessary treatment) Procedure Only (1 procedure and/or test) Second Opinion: (1 visit only)

*Referral Approval Number

*Policy # (Please note: If the patient has insurance, the policy number is required.)

Authorization #

For questions or concerns while using this form, email physicianservices@cmh.edu