Patient Referral Forms
- Referred Testing Form | fax to Patient Registration 205-638-5383
- Pediatric Imaging Center Order Form (Children's South only) | fax to 205-638-4803
- Request for a Specialty Clinic Appointment Form | fax to specialty on page 2 of form
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.
Some clinics/specialties 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.
Adolescent Health Center Referrals
For all special clinics listed below and general adolescent consults, please fax the Request for a Specialty Clinic Appointment Form (please specify which clinic below you are referring to) along with an insurance referral (if needed), growth charts, lab work obtained in the last 6 months, and clinic notes for the past year to 205-638-2071. Please also note some additional items as required for the specific clinic listed:
- ADHD: Print the ADHD Intake Packet for the parent. Please note that an appointment will not be made until the completed packet is received by the Adolescent Health Center.
- Eating Disorder: An Adolescent Medicine physician and dietitian staff the clinic providing treatment of disordered eating, including anorexia and bulimia nervosa, and diagnostic consultation for patients with weight loss, vomiting, or abdominal pain.
- LARC (Long Acting Reversible Contraception): all patients will be scheduled for a consult visit prior to being scheduled for LARC placement.
- LEAH (Leadership and Education in Adolescent Health): a multi-disciplinary clinic involving Adolescent Medicine, nursing, nutrition, psychology, and social work intended for patients with complex medical and psycho-social needs.
- Menstrual Disorder: Evaluation and treatment of menstrual problems in adolescents and young adults.
- Nutrition: Registered Dietitians provide nutrition assessments and counseling. This clinic DOES NOT include a medical provider. Adolescent Nutrition clinic requires a referral from a physician or nurse practitioner.
Children’s Behavioral Health - Partial Hospitalization Program (PHP)
- Referring provider fills out the Partial Hospitalization Referral Form 2780 (PDF)
- Fax form to 205-638-5061, or Email referral form to firstname.lastname@example.org.
- Call 205-638-5060 for questions or insurance eligibility.
- An intake appointment will be made with the patient to verify PHP is the appropriate level of care.
Gastroenterology, Hepatology and Nutrition
- All new patient appointments get scheduled through the Patient Access Center. A physician makes a referral, by filling out the Referral Form and faxing it to 205-638-9919, along with a Medicaid Referral (if this applies).
- If referring a patient for constipation the PCP Constipation Referral Checklist must be included.
- Fax all relevant* records, labs and imaging | 205-638-9919
- Genetics Referral Form
- Fax | 205-975-6389 Phone | 205-934-4983
- Fax patient demographic and insurance information, insurance referral, if needed, reason for the referral, last 2-3 clinic notes, labs.
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.
- A physician makes a referral by completing the Specialty Clinic Appointment Form and faxing it to 205-638-2602, along with a Medicaid Referral (if this applies).
- If referring a patient for headache, the PCP Headache Referral Checklist must be included.
- Fax all relevant* records, labs, EEG or EMG, and imaging reports to 205-638-2602.
PT & OT Referral Form
This form requires a physician's signature.
Rheumatology Referral Form
Fax | 205-638-2875 along with any relevant medical records
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.