Epidermolysis Bullosa (EB) Center

To get started on the information packet, you may download the patient forms in portable document format (.pdf) or Microsoft Word:

• Child Patient Questionnaire  .pdf | Word
• Adult Patient Questionnaire  .pdf | Word
• Insurance Questionnaire  .pdf | Word
• Referral Form .pdf | Word
• EB Providers / Services Form  .pdf | Word
• Food Intake Form .pdf | Word 
  Please record three days of intake 
• Instructions for Food Intake Form .pdf

Please fill out all of the forms completely and return them as soon as possible. The forms can be sent to the Epidermolysis Bullosa Center by mail or email. Visit our Contact Us page for complete mailing information.

An official appointment cannot be scheduled until all forms are returned to us. Once we have received the forms, we will contact you to confirm your appointment date and time.

One of the benefits of the EB Center is that your child will be seen by several specialists in a single visit. While the schedule of visits will be more convenient for your family, the referral process and co-payments will not change. For example, if your insurance provider requires you to pay a $10 co-pay per physician visit, and your child is seen by three specialists, the total amount owed would be $30.

We advise you to contact your insurance company to verify your benefits and coverage. There may be charges your insurance company will not cover, such as co-payments, deductibles or out-of-pocket expenses. In addition, you may need to obtain referrals for each physician. Pre-approval for a visit does not guarantee your claim will be paid. Please check with your insurance company.

Co-payments are due when services are provided to your child. We will not know the number of physicians examining your child until the time of the visit, so be prepared to pay as many as six co-payments.

Contact your health insurance provider to obtain prior authorization before your first visit with the Epidermolysis Bullosa Center.

Here are the steps to get your health insurance provider to cover your visit:

• Call your health insurance provider and explain the visit.
• Ask your insurance company if Cincinnati Children’s Hospital Medical Center is a provider. (We may also be listed as Children’s Hospital Medical Center of Cincinnati.)
• Verify coverage and whether a referral from your child’s primary care physician is needed.
• Additional documentation may be needed from other local providers.
• Contact Patient Financial Counseling if you feel you may need financial assistance, 513-636-8891.