Today's Date
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Today M-D-Y
Today M-D-Y
Child's First Name
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As shown on insurance card.
Child's Last Name
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As shown on insurance card.
Male Female
Date of Birth
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M-D-Y
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Total Age in Months (AS OF TODAY)
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Age Bucket (total months) - AS OF TODAY
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View equation Parent/Guardian First Name
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Parent/Guardian Last Name
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Relationship to the patient:
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Biological Parent Foster Parent Case Worker Other
Please explain the relationship to the patient:
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Parent/Guardian Phone Number
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This email address will be used to communicate about the status of this referral.
Current city where patient lives
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What is the zip code where the family currently lives?
Select the option that best describes your patient:
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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 difficulties
My patient is 3 years or older and has severe problem behavior
My patient is 4 years or older and needs toilet training
My patient has been formally diagnosed with ASD and needs intensive support for improving communication
My patient is 3 years or younger and has social communication delays
EarliPoint in Forsyth (must be 16-30 months)
Thank you for your referral to the Severe Behavior Program.
Severe Behavior serves patients with significant challenging behaviors including aggression (hurting others), disruptive/destruction behaviors, self-injurious behaviors (hurting self), elopement (running away), noncompliance, and/or pica (eating non-food items).
To be seen in the Severe Behavior Program, the patient will need the following:
Psychological Evaluation and/or Diagnostic Report from a Licensed Psychologist and/or MD. Should have a diagnosis of ASD or related Developmental Delay within the last 5 years. Letter of Medical Necessity (LOMN) A live signature is required by many insurance companies. Please do not type name as signature. Download a copy of a LOMN template here. Appointments will not be scheduled without required documents.
Thank you for your referral to the Severe Behavior Program.
Severe Behavior serves patients with toilet training needs. We offer a toilet training consultation program as well as provide intensive toilet training for enuresis and encopresis.
To be seen in the Toileting Training Program within Severe Behavior, the patient will need the following:
Psychological Evaluation and/or Diagnostic Report from a Licensed Psychologist and/or MD. Should have a diagnosis of ASD or related Developmental Delay within the last 5 years. Letter of Medical Necessity (LOMN) A live signature is required by many insurance companies. Please do not type name as signature. Download a copy of a LOMN template here. Appointments will not be scheduled without required documents.
A Letter of Medical Necessity is essential to process the referral Download a copy of a Letter of Medical Necessity template here. Note: A live signature is required by many insurance companies. Please do not type name as signature.
The Marcus Early Intervention Program requires a prescription for Speech services. Download a copy of a Speech Rx template here. Note: A live signature is required by many insurance companies. Please do not type name as signature.
Upload the completed Letter of Medical Necessity here
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Upload the Diagnostic Report here
Upload the completed speech services prescription here.
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Please note, due to high demand we do not provide second opinions or re-evaluations for children who have already been diagnosed with autism by a clinical psychologist, neurologist or developmental pediatrician. Please note that Aetna does not cover EarliPoint testing.
If the family has Aetna coverage, they will be offered a self pay option (< $150), or non-EarliPoint diagnostic testing.
Was the child born at 33 weeks or earlier?
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Yes
No
Unknown
Does the child have any known genetic disorders OR a seizure disorder?
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Yes
No
Unknown
Does the child wear glasses?
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Yes
No
Unknown
What is the family's preferred language?
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Please select the service you are requesting for your patient:
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Medical services with a developmental provider
Psychiatric services and medication management
No ASD diagnosis required. Appropiate patients for our feeding disorders program are formula or liquid dependent, tube fed, have food restriction causing malnourishment, etc. Additional Feeding Information
My patient has dysphagia and would benefit from additional workup by ENT, GI, Nutrition, and Speech
My patient accepts a limited volume or variety of food by mouth
My patient has a complex medical history and would benefit from consultation with GI and Nutrition to optimize growth
A diagnosis of Autism is not required for Early Intervention services, though other documentation is necessary. Please confirm your e-mail address, telephone and fax numbers are correct before submitting this form. If you have a copy of the child's hearing screen, please upload here.
Please provide more detail on why you are referring your patient to Marcus Autism Center:
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Select one that best describes your patient:
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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
Select the PRIMARY service that you are seeking for your patient:
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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).
Treatment for social or individual communication or language delays (Must have a documented diagnosis of ASD or Developmental Delay if older than 3)
PLEASE COMPLETE THE MEDICAL INFORMATION BELOW:
Please select the primary service you are requesting.
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. .
Please select the characteristics of autism that you have concerns for and are requesting a formal evaluation for ASD.
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)
Select the primary service that you are interested in referring this child.
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
Parent Training for Early Intervention (children 3 and under with individual or social communication delays)
Other
Licensed Healthcare Provider Name
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Provider's National Provider Indentificaion (NPI)
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Practice Name
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Group or Organization Name
Practice City and State
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Provider Phone Number
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Provider Email Address
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This email address may be used to communicate with you about the status of this referral and/or request additional information needed.
I certify that I am the child's healthcare provider or office representative of the healthcare provider completing this form.
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Yes No
Please contact your child's healthcare provider to submit our online provider referral form at www.marcus.org to request services for your child. Name of office representative completing this form
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Phone contact information for office representative
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It was indicated that named caregiver is the (______ )
Has required legal documentation been received and registration cleared and noted in EPIC?
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Yes No
STOP! EPIC MRN Number
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Ensure MRN and Name matches EPIC record
Registration Completed by:
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Adriania Slaughter Alvin Kimbrough Ana Angulo-Nazarbaghi Emmie Wilson Jose Sanchez Kevin Jennings Livet Owens Nekeisha Watson Rose Slater Sabrina Williams Stacey White Valerie Benjamin Other
Date Registration Cleared
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Today M-D-Y
Timestamp for generating reports
Today Y-M-D