Chla migratedOutpatientReferralFormOutpatient Referral Form - Children's Hospital Los Angeles 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This is essential for tracking your referral.
3. In Section I, provide your information as the referring physician. Fill in your first and last name, office address, phone number, fax number, and email address. If there is a contact person other than yourself, include their name.
4. Move to Section II to input patient and family information. Enter the patient's first and last name, date of birth, gender, primary language, and guardian details including their names and contact information.
5. In Section III, indicate whether the referral is urgent or routine. Specify the requested specialty or specialist along with the reason for referral/diagnosis and preferred location from the options provided.
6. Finally, complete Section IV by selecting the patient’s insurance type and providing necessary details such as insurance carrier and subscriber ID. Ensure you attach any required prior authorization documentation if applicable.

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