Healthcare Professionals

Forms and Guidelines

The staff at Cincinnati Children’s Hospital Medical Center believes that building collaborative relationships with primary care physicians helps achieve the best outcomes when treating patients.

One call to our Physician Priority Link  will tell you everything you need to know to refer a patient to Cincinnati Children’s. And, you can download any form you need right here.

Referral / Consult Form Process

Test and procedure referral forms are required by Cincinnati Children’s to schedule procedures. These forms must be completed and faxed to the Cincinnati Children’s Scheduling Center as indicated on each form. 

Download Order and Referral / Consult Forms

All referral / consult forms are provided in .pdf format.

Outpatient Referral Forms

• Request for Specialty Services  
• Radiology Services Order Form (includes both Radiology and Nuclear Medicine)
• Diagnostic Testing Order Form (includes EKG, ECHO, EEG, EMG, PFT, DXA Scan, GTT and Sweat Chloride)
• Occupational Therapy / Physical Therapy / Speech Pathology / Audiology Services Order Form  

Walk-in Services

• Ancillary Order Form  

Home Health Care Services

• Home Health Orders / Nurse Visits / HME Supplies 
• Synagis Order Form
• Synagis - Statement of Medical Necessity
• Home Health Nurse Visits for Asthma
• Phototherapy Orders
• Home Health Supplies / Equipment Only  

Other Referral Forms

• ED Referral Form  
• ED Referral Guidelines 
• Interventional Radiology Referral Form  
• Pre-Procedure Physical Exam Form  
• NCA Follow-Up Referral Form
• Pathology Consultation Request Order Form

Release of Information Forms

• Confirmation of Treatment Relationship
• Authorization for Use and / or Disclosure of PHI
• Authorization for Use and / or Disclosure of Psychotherapy Notes