newtm kids patient label triage referral form · triage referral form patient label date: thank you...

C7453N (06/17) NEW TM Kids Triage Referral Form PATIENT LABEL Date: Thank you for referring your patient to the NEW ™ Kids Triage at Children’s Hospital of Wisconsin. Please complete the following information, verify insurance referrals and forward referral as indicated below. Once veriﬁed, a CHW representative will contact the family within 7 days to schedule an appointment in the NEW Kids Triage clinic. Patient information Patient Name: Date of Birth: Language: Parent/Guardian Name: Patient Address: Home Phone Number: Work/Cell Number: Insurance Carrier: Referring Provider Information Provider Name: Provider Address: Phone Number: Fax Number: *BMI for Age MUST be at or greater than 85%ile or Z score 1.03 Date of Measurement: _____________ Height: ______ Weight: ______ BMI: ______ BMI %ile or Z score: ______ *The patient MUST have one of the co-morbidities listed below or abnormal lab result in a category below to qualify for our program. Fasting lab values must be received with this referral. Date of fasting labs: Total Cholesterol: <170 mg/dL LDL Cholesterol: <110 mg/dL HDL Cholesterol: >35 mg/dL Triglycerides: <125 mg/dL Insulin Level: <15 u/L Glucose: <100 mg/dL HA1C: <5.7% AST: <50 u/L ALT: <35u/L Polycystic Ovarian Syndrome (PCOS) Non-alcoholic Steatohepatitis (NASH) Non-alcoholic Fatty Liver Disease (NAFLD) (Date of liver biopsy showing NAFLD/NASH ) Hypertension (3 abnormal readings ) Blount’s Disease Pseudotumor Cerebri Slipped Capital Femoral Epiphysis (SCFE) Sleep Apnea (Date of sleep study ) Additional pertinent medical history: ** Please fax this form to 414-266-4709 along with recent clinic note, lab values and growth chart. OFFICE USE ONLY Date Received: Date of Appointment: Provider: Referral denied reason: Any additional comments: APPLY DT BARCODE STICKER MD Referral Accepted DT 346 MD Referral Denied DT 9901 Phone: 414-266-4112 Fax: 414-266-4709

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Page 1: NEWTM Kids PATIENT LABEL Triage Referral Form · Triage Referral Form PATIENT LABEL Date: Thank you for referring your patient to the NEW ™ Kids Triage at Children’s Hospital

C7453N (06/17)

NEWTM KidsTriage Referral Form PATIENT LABEL

Date: Thank you for referring your patient to the NEW ™ Kids Triage at Children’s Hospital of Wisconsin. Please complete the following information, verify insurance referrals and forward referral as indicated below. Once verified, a CHW representative will contact the family within 7 days to schedule an appointment in the NEW Kids Triage clinic.Patient informationPatient Name: Date of Birth: Language: Parent/Guardian Name: Patient Address: Home Phone Number: Work/Cell Number: Insurance Carrier:

Referring Provider InformationProvider Name: Provider Address: Phone Number: Fax Number:

*BMI for Age MUST be at or greater than 85%ile or Z score 1.03

Date of Measurement: _____________ Height: ______ Weight: ______ BMI: ______ BMI %ile or Z score: ______*The patient MUST have one of the co-morbidities listed below or abnormal lab result in a category below to qualify for our program. Fasting lab values must be received with this referral.

Date of fasting labs: Total Cholesterol: <170 mg/dLLDL Cholesterol: <110 mg/dLHDL Cholesterol: >35 mg/dLTriglycerides: <125 mg/dL

Insulin Level: <15 u/LGlucose: <100 mg/dLHA1C: <5.7%AST: <50 u/LALT: <35u/L

Polycystic Ovarian Syndrome (PCOS) Non-alcoholic Steatohepatitis (NASH) Non-alcoholic Fatty Liver Disease (NAFLD)(Date of liver biopsy showing NAFLD/NASH ) Hypertension (3 abnormal readings )

Blount’s Disease Pseudotumor Cerebri Slipped Capital Femoral Epiphysis (SCFE) Sleep Apnea (Date of sleep study )

Additional pertinent medical history: ** Please fax this form to 414-266-4709 along with recent clinic note, lab values and growth chart.OFFICE USE ONLYDate Received: Date of Appointment: Provider: Referral denied reason: Any additional comments:

APPLY DT BARCODE STICKERMD Referral Accepted DT 346MD Referral Denied DT 9901

Phone: 414-266-4112 Fax: 414-266-4709

Plate: Black

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