Provider Referral Form

This form is to be completed by the licensed healthcare provider that is familiar with the care of the patient.

*The healthcare provider's National Provider Identification (NPI) number will now be required to submit this referral.

Please make sure to complete all required fields, we are not able to process incomplete referrals.

M-D-Y

Male Female

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M-D-Y

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I would like my patient to be evaluated for Autism Spectrum Disorder (ASD)

My patient has been formally diagnosed with ASD and needs medical follow-up

My patient has severe feeding dificulties

My patient is 3 years or older and has severe problem behavior

My patient is 4 years or older and needs toilet training

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Please note, due to high demand we do not provide second opinions or re-evaluations for children who have autism eligibility in the school or who have already been diagnosed with ASD by a clinical psychologist, neurologist or developmental pediatrician.

Medical services with a developmental provider

Psychiatric services and medication management

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*Records confirming the ASD diagnosis will be required during our pre-appointment process.
Appointments will not be scheduled without required documents.

No ASD diagnosis required. Appropiate patients for our feeding disorders program are formula or liquid dependent, tube fed, have food restriction causing malnourishment, etc.

Must have documented diagnosis of ASD or Developmental Delay. Appropiate patients for our Severe Behavior Program have aggression (hurting others), self-injurious behavior, elopement and pica.

*Records confirming the diagnosis will be required during our pre-appointment process.
Appointments will not be scheduled without required documents.

Must have documented diagnosis of ASD or Developmental Delay.

*Records confirming the diagnosis will be required during our pre-appointment process.
Appointments will not be scheduled without required documents.

Expand

I suspect my patient may have Autism Spectrum Disorder (ASD) (i.e. with or without developmental delay).

My patient has been formally diagnosed with ASD (this includes diagnoses of Aspergers, pervasive developmental disorder, or autistic disorder).

My patient does NOT have ASD but have concerns about feeding

I do NOT suspect my patient of having ASD, but does have a developmental delay

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1st time evaluation to determine if my patient has ASD. (Because of high demand for undiagnosed children, we do not provide second opinions or re-evaluations for children already diagnosed by a clinical psychologist/neurologist/developmental pediatrician or who have Autism eligibility in school).

Medical follow-up with a developmental specialist. (Must have a documented diagnosis of ASD already).

Psychiatry services/Medication management (Must have a documented diagnosis of ASD already).

Treatment for severe feeding difficulties. (Formula or liquid dependence, tube feeding, food restriction causing malnourishment, ect).

Treatment for severe problem behaviors (Must have a documented diagnosis of ASD or Developmental Delay) (Aggression, elopement, toileting, self-injury, ect).

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Prematurity (gestational age)

Cerebral palsy or other brain injury/abnormality

Seizures/Epilepsy

Developmental regression

Genetic syndrome

Hearing Impairment

Vision Impairment

Cardiac defect

Other relevant medical condition

No known medical problems

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NEW ASD DIAGNOSIS (The child needs a formal evaluation to determine if he/she has Autism (ASD).

ESTABLISHED ASD DIAGNOSIS The child has already been evaluated and received a formal diagnosis of Autism (ASD) and needs the following service.

Child does NOT have AUTISM but have concerns about feeding.

Child does NOT have AUTISM but has a diagnosis of developmental delay and/or intellectual disability and have concerns about problem behavior management..

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SOCIAL CONCERNS (less eye contact, difficulty understanding the emotions and feeling of others, problems making and keeping friends.

COMMUNICATION CONCERNS (lack of speech,slow to learn speech, unusual speech (repeats things, unusual sounds), difficulty making conversation.

REPETITIVE BEHAVIOR OR RESTRICTED INTERESTS (rocks, spins, flaps hands, uncommon strong limited interests, plays with parts of toy i.e. spins wheels of toy car).

PROBLEM BEHAVIORS (aggressive towards others, hits,bites, kicks, self injurious behavior, head bangs, scratches self, picks at skin, elopement, PICA (chews/mouths vs swallows)

Developmental follow-up .

Medication Management (initiation of medication or management of existing meds)

Behavioral management (does not include medication management)

Neurological evaluation (please state specific concern)

Neurodiagnostic testing (EEG, Neuroimaging, Genetic testing)

Language and Skill Acquisition (ABA therapy)

Feeding Evaluation

Other

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Yes No

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Please contact your child's healthcare provider to submit our online provider referral form at www.marcus.org to request services for your child.

Scheduling Team Section

Yes No

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STOP!
Legal documentation must be received before registration can be cleared.

M-D-Y

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Required format:

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GcTdcrKin5XHguSYtze6jJFPeFnMnPWCnxkeBYJQwWSEmLTiuyRkZ3RNdsDy

Please note, due to high demand we do not provide second opinions or re-evaluations for children who have autism eligibility in the school or who have already been diagnosed with ASD by a clinical psychologist, neurologist or developmental pediatrician.

*Records confirming the ASD diagnosis will be required during our pre-appointment process. Appointments will not be scheduled without required documents.

No ASD diagnosis required. Appropiate patients for our feeding disorders program are formula or liquid dependent, tube fed, have food restriction causing malnourishment, etc.

Must have documented diagnosis of ASD or Developmental Delay. *Records confirming the diagnosis will be required during our pre-appointment process. Appointments will not be scheduled without required documents.

Please contact your child's healthcare provider to submit our online provider referral form at www.marcus.org to request services for your child.

Scheduling Team Section

STOP! Legal documentation must be received before registration can be cleared.

*Records confirming the ASD diagnosis will be required during our pre-appointment process.
Appointments will not be scheduled without required documents.

Must have documented diagnosis of ASD or Developmental Delay.

*Records confirming the diagnosis will be required during our pre-appointment process.
Appointments will not be scheduled without required documents.

STOP!
Legal documentation must be received before registration can be cleared.