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Click ‘Get Form’ to open the Intake Form in the editor.
Begin by filling out the 'Patient Information' section. Enter your child's first, middle, and last name, date of birth, place of birth, gender, diagnosis, symptoms, and country of residence.
Next, complete the 'Family and Contact Information' section. Provide details for both parents including names, dates of birth, email addresses, telephone numbers, home addresses, countries of residence, and primary languages.
If applicable, fill in the 'Guardian/Other Contact' information with similar details as required for parents.
In the 'Clinical Information' section, enter your physician's name and contact details. Indicate whether clinical information is available.
Proceed to the 'Payment Information' section to specify how you will be paying for services.
Fill out the 'Travel Information' section with your planned timeframe for traveling to Los Angeles.
Finally, review the checklist at the end of the form to ensure all required documentation is prepared for submission.
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The hospital provides comprehensive pediatric specialties and subspecialties to infants, children, teens, and young adults generally aged 021 throughout California and the west coast. The hospital also sometimes treats adults that require pediatric care.
What paperwork is needed to take a child to the hospital?
Important documents to bring It can be helpful to bring copies of important documents such as your childs birth certificate, Social Security numbers, insurance cards, legal papers, and medical records.
What is the phone number for chla help desk?
If you are a myCHLA user and need support with an active account, please call 888-631-2452 - Opens in a new window and select the option for myCHLA or contact the CHLA Help Desk at help@chla.usc.edu - Opens in a new window.
What is the No. 1 childrens hospital in the US?
Speak with the patients primary care doctor (pediatrician) or call 1-888-631-2452 to speak with a representative who can assist.
How to make an appointment at UCLA Medical Center?
Make an Appointment Book Online. New patients can check availability online and schedule an in-person visit or a virtual consultation with a primary care provider. Schedule Through the Patient Portal. Request an Appointment. Book by Phone.
Related Searches
Childrens hospital Los Angeles EINCHLA authorization formChildren's Hospital Los Angeles medical recordsChildren's Hospital Release of information formInside CHLAChildren's Hospital medical record requestCHLA benefitsThe Children's Hospital
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0:15 1:35 Next choose a location the provider you would like to see and a date and time. If youre not seeingMoreNext choose a location the provider you would like to see and a date and time. If youre not seeing a time you like try choosing any location or any provider to broaden your. Options.
Related links
Childrens Hospital, Los Angeles
Intake Assessment Forms CDI and Mid-Tx Forms PDI and Graduation Forms DPICS 323-361-7827. Contact Email. krogers@chla.usc.edu. Address1. 4650 Sunset
Childrens Hospital of Los Angeles * - Medical Hubs
The CHLA Hub serves DCFS-involved children by providing initial medical and mental health Hub evaluations and by providing recommendations and follow-up.
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