Community 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 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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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)

Feeding Evaluation

Therapies (Speech therapy, Occupational therapy, or ABA therapy).

Other

We are not accepting new referrals for Neurology services at this time. Please make another selection or if you have questions, contact us at 404-785-9400.

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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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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

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/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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/^-?\d+,\d$/

/^-?\d+\.\d$/

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ttDjjGuRxpCAsQqIpuA6TxZh2xPPTZ9a4gvxYuLJ6PNyZIDHNkXWIK2oTGPCDn6fSCWcfQdsusGUYkEhpvsYQFGt57K5jA9oJ

We are not accepting new referrals for Neurology services at this time. Please make another selection or if you have questions, contact us at 404-785-9400.

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.

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