CHO+Specialty+Referral+Info

CHO Specialty Clinic |||| Complete CHO “Patient Evaluation Form” and fax with appt. notes/labs/Xrays etc. |||| Complete and fax CCHP Prior Authorization form (313-6058) |||| Complete CCS application/request for service form, fax to CCS (313-6115) |||| Number to call for appt. **AFTER** authorization is obtained (if TO can make appt immediately) || ||||  **YES** Fax: 510- 450-5631 ||||  **YES (if TO, GO, H9, AO)** (//Hearing loss// is CCS eligible) |||| Phone: 510- 428-3344 || **YES** Fax: 510- 428-3381 |||| (Most //cardiac diseases, primary HTN, cardiac dysrhythmias// are CCS eligible**)** |||| Phone: 510-428-3380 || **NO** complete ‘Intake Referral Form” specific to this clinic only Fax: 510- 601-3912  ||||   **NO** (developmental delays and behavioral issues are **NOT** CCS eligible) |||| D. O’Hara Intake Coordinator 510-428-3351 X4353 (packet will be mailed to family to complete & mail back before appt can be scheduled) || ||||  **NOT REQUIRED BUT MAY BE USED-**call before faxing any information Fax: 510- 601-3989 ||||  ||||   **YES (TO, GO, H9, AO) (**//cleft lip/palate, other congenital anomalies or ‘severely disfiguring’ conditions//) |||| Valerie or Gloria 510- 428-3150 (family will be contacted after review of referral by medical staff) || **NO** Fax an **rx** or **EEG requisition** with pertinent medical info to: 510-601-3974 |||| **NO** no P/A needed for GO, HO, H9 |||| **YES** (if CCS eligible condition) ***seizure d/o is not CCS eligible** || 510-428-3209 or 510-428-3590 || **YES** Fax: 510- 450-5614 (include growth chart with referral) |||| (if HO, or if not a CCS eligible condition) |||| **YES** (examples of CCS eligible conditions //diabetes, thyroid, pituitary, growth hormone deficiency//) || 510-428-3654 || **YES** Fax: 510- 450-5613 ||||  **YES** (if HO, or not CCS eligible) |||| **NO** (tends not to be CCS eligible) || 510- 428-3233 ||  **YES** Fax: 510- 587-7172 ||||  **NO ** (for GO, HO, H9 no P/A needed) **YES **(if AO) |||| **YES** (if CCS eligible, examples: //ROP, strabismus requiring surgery, cataract, glaucoma, retinal detachment,, ptosis, congenital eye anomalies//) || 510- 428-3226  (appts.) 510- 428-3050  (clinic) **YES** Fax: 510- 450-5813 ||||  **YES** (for HO, or if not CCS eligible dx) |||| **YES** (if CCS eligible: //liver failure, pancreatitis, peptic ulcer, congenital anomalies//) || 510- 428-3058 ||  **YES** **Hemophilia & general hematology:** ask for Jim Rydell RN **Sickle cell:** ask for Pat Shields RN  Provider usually calls on-call MD  Fax: 510- 601-3916 |||| **YES** **YES** (CCS eligible: //hemophilia, sickle cell, hemolytic anemias, coagulation disorders, platelet disorders, all malignant neoplasms// are CCS eligible)  || 510-428-3372 || **YES** 510-450-5874 *note if family is Spanish speaking |||| **YES** |||| **NO** ‘syndromes’ are not CCS eligible || 510-428-3550 Clinic staff will contact family with appointment || Complete ‘MRI Patient Screening’ & ‘MRI Safety Questionnaire’ and fax to: 510-450-5814) ||||  **NO**   (only if anesthesia is needed) ||||  **YES**  (for CCs eligible conditions only) ||  510-428-3410 ||  **YES**  Fax: 510- 450-5850 ||||   **YES**  (if HO, or not CCS eligible) ||||   **YES**  (if CCS eligible: //reflux grade II or >, hydronephrosis, obstructive uropathies//) ||  510-  428-3335 ||  **YES**  Fax: 510- 601-3974 ||||   **YES**  (if HO, or not CCS eligible)  ***seizure disorder is not generally CCS eligible** ||||   **YES**  (if CCS eligible: //brain tumor, tuberous sclerosis, some cerebral palsy, status epilepticus//) ||  510-  428-3590 ||  **YES**  Fax: 510- 597-7034 ||||   **YES** (if ‘HO’ or not CCS eligible dx) ||||   **YES**  (If CCS eligible: //congenital spine anomalies, spina bifida, hydrocephalus, craniosynostosis, skull fracure//) ||  510-  428-3319 ||  **YES**  Fax: 510- 601-3904 ||||   **YES**  (if ‘HO’ or not CCS eligible) ||||   **YES**  (If CCS eligible: //club foot, JRA, dystrophies, myasthenias, scoliosis > 20 degrees//) || 510- 428-3238 ||  **YES** Fax: 510- 450-5821 *if requesting PT/OT write rx with dx. ||||  **YES** (if ‘HO’ or not CCS eligible diagnosis) |||| **YES** (If CCS eligible: //muscular dystrophy, cerebral palsy, any traumatic injuries or conditions that require physiatrist intervention//) || 510-428-3655 (after appt. scheduled, clinic will generate client specific form to be completed by referring provider ||  **YES**  Fax: 510-  597-7154 ||||   **YES**  (if ‘HO’ or not CCS eligible dx) ||||   **YES**  (if CCS eligible: //cystic fibrosis, CLD, respiratory failure, BPD//) ||  510-428-3305 || Fax: 510-  450-5678 ||||   **YES **(If ‘HO’ or not CCS eligible dx) ||||   **YES **(if CCS eligible: //lupus, JRA, scleroderma//) ||  510-428-3304 ||  ||||  Fax: 510-  428-3405 ||||   **YES**  (unilateral undescended testicle, inguinal/umb. hernias are **not** CCS eligible) ||||  **YES**  (if CCS eligible: //reflux grade II or >, traumatic injuries//)  ||  510-428-3022 ||
 * AUDIOLOGY **
 * AUDIOLOGY **
 * YES (if HO) ** ||||
 * CARDIOLOGY ** ||||
 * CARDIOLOGY ** ||||
 * YES (if HO) ** ||||
 * YES (if TO, GO, H9, AO) **
 * CHILD DEVELOP-MENT/ **
 * BEHAVIORAL PEDIATRICS ** ||||
 * BEHAVIORAL PEDIATRICS ** ||||
 * *specify if family is Spanish speaking. **
 * YES **
 * (if GO, H9, HO, A0) ** ||||
 * CRANIO-FACIAL **
 * YES (HO) **
 * EEG ** ||||
 * EEG ** ||||
 * ENDOCRINE ** ||||
 * ENDOCRINE ** ||||
 * YES **
 * ENT ** ||||
 * ENT ** ||||
 * EYE CLINIC (OPTHAM-OLOGY) ** ||||
 * EYE CLINIC (OPTHAM-OLOGY) ** ||||
 * *5275 Claremont Ave. ** ||
 * GASTRO-ENTEROLORY ** ||||
 * GASTRO-ENTEROLORY ** ||||
 * HEM/ONC ** ||||
 * HEM/ONC ** ||||
 * Oncology **
 * (if HO) ** ||||
 * (TO, GO, H9, AO) **
 * MEDICAL GENETICS ** ||||
 * MEDICAL GENETICS ** ||||
 * (generally) **
 * MRI ** ||||
 * NO **
 * NO **
 * NEPHROLOGY ** ||||
 * NEPHROLOGY ** ||||
 * NEUROLOGY ** ||||
 * NEUROLOGY ** ||||
 * NEURO-SURGERY ** ||||
 * NEURO-SURGERY ** ||||
 * ORTHO-PEDICS ** ||||
 * ORTHO-PEDICS ** ||||
 * PEDI REHAB ** ||||
 * PEDI REHAB ** ||||
 * PULMONARY ** ||||
 * PULMONARY ** ||||
 * RHEUMA-TOLOGY ** ||||
 * RHEUMA-TOLOGY ** ||||
 * SURGERY/ **
 * UROLOGY **
 * UROLOGY **
 * PEDIATRIC SURGICAL ASSOCIATES **