Patient Referral Forms

Referring Patients

Step 1

See "How to Schedule Appointments" on the back of the form for further records requested by the specialty. Please fax these documents at the same time you fax this form to keep records and forms together, and eliminate duplication of tests performed. If insurance requires a referral (Medicaid, etc.), please fax referral with this form.

Step 2

Some clinics/specialities require additional information about the patient to better understand their history and develop a treatment plan.

Children's of Alabama specialists offer excellent pediatric care for Alabama's children. You may refer patients to the hospital, a particular service, or to an individual specialist for consultation, diagnosis or treatment.


Developmental Medicine Clinic Referral Form
Fax | 205-212-2994. Please include any relevant clinic notes and records.
Also have family complete and return the Intake Form appropriate for the patient’s age:

Hearing and/or Speech Evaluation Referral Form

  • Fax the completed form along with any relevant medical records | 205-638-3680

Hypertension Clinic Referral Form
Fax | 205-975-7051. Please attach any lab and diagnostic testing reports.

Intensive Feeding Program Supplemental Referral Form
Fax | 205-638-7995. This form requires a physician's signature.

Medical Autism Clinic Referral Instructions
Fax | 205-212-2997. This form requires a physician's signature.

PT/OT Referral Form
This form requires a physician's signature.

Specialty Clinic Appointment Form

Also have family complete and return the Intake Form appropriate for the patient’s age:

Rheumatology Referral Form
Fax | 205-212-2734 along with any relevant medical records

Sleep Study (Polysomnogram) Referral Form
Fax | 205-638-2466. This form requires a physician’s signature.

Whole Genome Sequencing (WGS) Application
Fax | 205-934-4111. Program Coordinator Tammi Skelton

Weight Management Referral

  • The Primary Care Physician must complete the Request for a Specialty Clinic Appointment Form and fax along with insurance referral (Medicaid referrals must be cascading and include current EPSDT date), growth chart, lab work obtained in the last 6 months, and clinic notes to 205-212-2735.
  • Please have the family complete the New Parent Evaluation Form and fax along with the Request for a Specialty Clinic Appointment Form to 205-212-2735. If the Parent Evaluation Form is not received with the referral we will mail the family instructions. We will not schedule an appointment until Parent Evaluation Form is received in our office.
  • We will mail family appointment date/time and fax Primary Care Physician appointment date/time.