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- Click ‘Get Form’ to open the chla referral form in the editor.
- Begin by entering the date at the top of the form. This is essential for tracking your referral.
- 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 another contact person in your office, include their name as well.
- Move to Section II for patient and family information. Enter the patient's first and last name, date of birth, gender, primary language, and details about the parent or guardian including their contact numbers.
- In Section III, specify the requested specialty or specialist and provide a reason for the referral. Select a preferred location from the options provided.
- Finally, complete Section IV with insurance information. Indicate the type of insurance and fill in the carrier details along with any required authorization information.
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How do I schedule an appointment at CHLA?
Speak with the patients primary care doctor (pediatrician) or call 1-888-631-2452 to speak with a representative who can assist.
What is a referral form in healthcare?
A patient referral form is a document used by healthcare providers to refer a patient to another specialist or healthcare service. The form typically includes patient information, the reason for the referral, medical history, and other relevant details to ensure continuity of care.
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.
Does CHLA accept Medi-Cal?
The CHLA Hub is available to children and teenagers who have Medi-Cal Benefits. Parking Instructions: The CHLA HUB clinic is located on the 6th floor, 3250 Wilshire Blvd, Los Angeles, CA 90010, corner of Wilshire Blvd and New Hampshire Ave, one block west of Vermont Ave.
What is the fax number for CHLA referral?
To refer a patient via fax, please download and complete the Outpatient Referral Form. Fax it to 323-361-8988.
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What is the phone number for CHLA referral?
Call 1-888-631-2452 for assistance with inpatient admissions and outpatient referrals.
Related links
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