OHSU Child Development and Rehabilitation Center Referral Form
This file contains the referral form for OHSU's Child Development and Rehabilitation Center (CDRC). The form must be completed by a medical professional. It outlines the patient demographics, diagnosis, and specific programs or services required.
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How do I fill this out?
To fill out this form, complete the patient demographics section, describe the concerns, and specify any necessary programs or services. Ensure all required fields are completed by a medical professional. Follow the instructions to submit the form.
How to fill out the OHSU Child Development and Rehabilitation Center Referral Form?
1
Complete the patient demographics section.
2
Specify the patient's current diagnosis if available.
3
Describe the concerns and clinical questions.
4
Select the appropriate program or service if needed.
5
Submit the completed form as instructed.
Who needs the OHSU Child Development and Rehabilitation Center Referral Form?
1
Medical professionals referring patients with developmental concerns.
2
Parents or guardians seeking evaluation for their child's developmental issues.
3
Primary care physicians coordinating specialized care.
4
Healthcare providers identifying specific therapy needs for a patient.
5
Clinics referring patients to specialized programs or services at CDRC.
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What are the instructions for submitting this form?
To submit the CDRC referral form, fill out all required sections accurately. Then, submit the completed form via fax to 503-346-6854 or contact the OHSU Incoming Referral Center for additional assistance. For inquiries or to speak with a physician, call 503-346-0644. Ensure all patient information is current and complete to expedite the referral process. Follow the submission guidelines to ensure timely response and coordination of care.
What is the purpose of this form?
The purpose of the CDRC referral form is to facilitate the referral process for patients with developmental concerns to OHSU's Child Development and Rehabilitation Center. This form ensures that all necessary patient information, including demographics, diagnosis, and specific services required, is accurately collected. By completing and submitting this form, healthcare providers can coordinate appropriate care and support for the referred patients.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient being referred.
- 2. Parent/Guardian Name: The name of the patient's parent or guardian.
- 3. Language(s) spoken at home: The languages spoken in the patient's home.
- 4. Patient Sex: The patient's gender.
- 5. Date of Birth: The patient's date of birth.
- 6. Home Phone: The patient's home phone number.
- 7. Cell: The patient's cell phone number.
- 8. Preferred CDRC Location: The preferred location for the patient's CDRC services.
- 9. Interpreter needed: Indicates if an interpreter is needed for the patient.
- 10. Primary Care Professional: The patient's primary care professional.
- 11. Last Appointment with PCP: The date of the last appointment with the primary care professional.
- 12. PCP Phone Number: The phone number of the primary care professional.
- 13. PCP Fax: The fax number of the primary care professional.
- 14. Referring Professional: The professional referring the patient if not the PCP.
- 15. Last Appointment with Referring Professional: The date of the last appointment with the referring professional.
- 16. Referring professional phone: The phone number of the referring professional.
- 17. Referring professional fax: The fax number of the referring professional.
- 18. Insurance: The patient's insurance information.
- 19. Current Diagnosis: Indicates whether the patient has a current diagnosis and specifies it.
- 20. Concerns and Clinical Questions: Description of concerns and clinical questions that necessitate the referral.
- 21. Specific Program or Service: Identification of specific programs or services the patient is being referred to, such as Audiology or Physical Therapy.
What happens if I fail to submit this form?
Failing to submit the CDRC referral form may delay or prevent the patient's access to necessary developmental evaluations and services. Proper submission ensures a timely and coordinated care process.
- Delayed Evaluation: The patient may experience delays in receiving developmental evaluations.
- Lack of Coordinated Care: Failure to submit the form can result in a lack of coordination in the patient's care plan.
- Missed Services: The patient may miss out on essential services and programs they need.
How do I know when to use this form?
- 1. Developmental Concerns: When a patient shows signs of developmental issues requiring specialized evaluation and care.
- 2. Specific Therapy Needs: When specific therapy services such as Audiology or Physical Therapy are needed.
- 3. Pediatric Specialist Referral: When a primary care physician needs to refer a patient to a pediatric specialist at CDRC.
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