Referral Forms

Resource Referral Pad - Los Angeles Medical Home Project for CSHCN

Resource Referral Pad: A “prescription” pad to be used by providers as a checklist/tool for identifying community resources and contact information for children with special health care needs. Can also call (323) 913-4400 or e-mail Lori Thompson to request in pad form (100 per pad). 

Referral Fax Back Form
"In an effort to coordinate future care, please complete the information below and fax this form back to our office."

Emergency Department Referral Fax Form
"This patient has been referred to the Emergency Department by____.

The following is the past medical history and diagnosis that we have on record. Also included are:
Plan of care
Last visit
Other pertinent information.

Please notify ______
Upon arrival
A fter patient has been evaluated
O nly if significant problems arise"

Last Updated November 1, 2006