Refer a Patient to the Fetal Center

Patient Information

Provider Information

Referring Physician

Name Office Address Phone Fax

Primary OB (if different than referring physician)

Name Office Address Phone Fax

Insurance Information

Check if insurance card included in fax; following sections do not need completed Insurance Carrier Policy # Group # Subscriber Claims Address Insurance Carrier Phone

Referring Patient For

Check box if referral is for Fetal Echo / Cardiology only

Urgency Ht / Wt

* Referring office is responsible for obtaining Prior Authorization for the Fetal Echo

By referring for a Comprehensive Fetal Center Evaluation, you will allow NCH to evaluate and provide services as deemed necessary by The Fetal Center.

Consultation and imaging reports will be transmitted back to your office as fast as possible. In addition to these written materials, would you also like to receive a phone call from the consulting physician? Yes No If yes, phone number Text OK? Yes No

(Patient data will not be sent via text. Text will only be used to coordinate a telephone call)

Contact number for critical results or unexpected findings Is there an additional care provider (i.e. primary OB/GYN) that you would like us to include in post-consult communications? Yes No

If yes,

Name Phone Fax

NICU Parent Booklet

The Heart Center

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