REFER A PATIENT TO CHILDREN"S HOSPITAL

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Emergency Department Referral Form
Diagnostic Imaging Referral & Order Form
Pulmonary Function Test Request Form
Mental Health & Child Development Referral Form Complete the entire referral form to avoid any further delays. Include the following:
1. Insurance Card: ( fax copy; front and back)
2. Authorization: If insurance authorization is required for mental health services, the referring provider/primary care physician is required to obtain the initial authorization in order for us to schedule the appointment.
3. Medical Records: Fax all relevant medical records.
4. Review Period: Allow a 2-week review process before calling to schedule an appointment. Questions? Please contact us at: 510-824-8428

Download the appropriate Patient Referral Form.

Fax the completed referral form to: (510) 995-2955
or: (510) 995-2956

Use the Standard Referral Form with the exception of the four clinic referral forms listed below. (Emergency, DI, Pulmonary, Mental Health)

Specialty Care Clinics
When requesting Specialty Care Outpatient Clinic Appointments:

At the top of the Standard Referral Form, please check Preferred Location box.
View: Subspecialty Clinic Schedule

New Patient Referrals

Please include the following 6 items:

Physician Name, Office Address, Phone and Fax Number
Patient Name, Date of Birth and Parent or Guardian's Name
Reason for Referral
Clinic Name (see below for full list) or Physician Name you are referring to
Insurance Information for Patient
Authorization (when required)

Fax Referral Management Process

When received, your fax is stored on a secure server as a PDF.
A fax-confirmation reply is sent thanking you for the referral.
The fax-confirmation includes:
- Patient name
- Date of birth
- Department referred to
- Date and time we received your fax
Your referral is then routed to the appropriate department for processing.

Patient Referral FAQs

What if I need to send notes or an authorization later?

Children’s requires the patient information below to relate the new documents to the original referral.
Be sure the following information is printed legibly on the authorization or medical notes:
1. Patient Name
2. Birth Date
3. Referral Department Name
Fax completed forms to: 510-995-2955 or 510-995-2956
We will reply with a confirmation fax.

Should urgent referrals be sent to the fax line?
No. For urgent referrals, please call the specialty department directly and have the referring physician speak to the specialist on call. Specialties such as Cardiology and Hematology/Oncology use these consults to determine how soon a patient needs to be seen.

Who makes the appointment?
While some Children’s departments contact the family to schedule an appointment, your patient’s family should call the specialty department directly. Processing the fax referral will take up to one day. Ask the family to wait one business day from referral-receipt before calling.

Who do I call with questions?
Questions about the referral management system should be directed to your physician liaison. Call Physician Liaison Services at: 510-428-3043

If you wish to confirm that a specialty department received your referral, please call:
1-800-400-7337

How do I register as a referring office?
Your physician liaison will ask for a list of the physicians and NPs that refer patients from your office, along with your office fax number, and then assign you a referral fax number. If you don’t know who your liaison is, please call Physician Liaison Services at: 510-428-3043

Do you have a Patient Appointment Information Card I can offer to my patients?
Download an Appointment Information Card to give all the referral information to your patient.

2013 Referral Directory (print version available) Call: 510-428-3043		Physician Helpline: Quality Department Email: PhysicianHelpline@mail.cho.org Phone: 510-428-3828
DEPARTMENT	PHONE	CONTACT	EMAIL
Adolescent Medicine	(510) 428-3885 ext. 2742	Barbara Staggers. MD	Bstaggers@mail.cho.org
Anesthesiology	(510) 428-3070	Amit Gupta, MD	Agupta@mail.cho.org
Audiology	(510) 428-3344	Kelly Tremmwel-Howel, CCC-A, AuD	ktremmwellhowell@mail.cho.org
Blood and Marrow Transplant Program	(510) 428-3374	Mark Walters, MD	Mwalters@mail.cho.org
Cardiology	(510) 428-3380	Olaf Reinhartz, MD	Oreinhartz@mail.cho.org
Cardiothoracic Surgery	(510) 428-3294	Olaf Reinhartz, MD	Oreinhartz@mail.cho.org
Center For Child Protection	(510) 428-3759	James Crawford, MD	Jcrawford@mail.cho.org
Center For the Vulnerable Child	(510) 428-3148	Diana Kronstadt, EdD	Dkronstadt@mail.cho.org
Clinical Nutrition	(510) 428-3885 ext.2008	Karen Amorde-Spalding MS,RD, CSP	Kspalding@mail.cho.org
Cord Blood Program	(510) 428-3374	Mark Walters, MD	Mwalters@mail.cho.org
Cranofacial Center	(510) 428-3885 ext. 4891	Bryant Toth, MD,	btoth@mail.cho.org
Critical Care Services/ Intensive Care Unit	(510) 428-3719	Sharon Williams, MD	swilliams@mail.cho.org
Day Hospital	(510) 428-3372	James Feusner, MD	Jfeusner@mail.cho.org
Developmental and Behavioral Pediatrics	(510) 428-3385 ext. 5126	Lane Tanner, MD	Ltanner@mail.cho.org
Diagnostic Imaging	(510) 428-3885 ext. 2599	Ronald A. Cohen, MD	Rcohen@mail.cho.org
Early Childhood Mental Health Program	(510) 428-3885 ext. 5126	Lane Tanner, MD	Ltanner@mail.cho.org
Emergency Department	(510) 428-3259	Augusta Saulys, MD	Asaulys@mail.cho.org
Emergency Department 2	(510) 428-3259	Augusta Saulys, MD	Asaulys@mail.cho.org
Endocrinology/Diabetes	(510) 428-3654	Jenny Olson, MD	Jeolson@mail.cho.org
Family Outreach Support Clinic	(510) 428-3129	Patricia Chase, MD	Pchase@mail.cho.org
Gastroenterology/ Hepatology/Nutrition	(510) 428-3885 ext. 2012	Elizabeth Gleghorn, MD	Egleghorn@mail.cho.org
Hand and Microsurgery	(510) 428-3024	Chau Tai, MD	dr.Ctai@gmail.com
Hematology/Oncology	(510) 428-3651	Elliott Vichinsky, MD	Evichinsky@mail.cho.org
Hospitalist	(510) 428-3237	Ted Chaconas, MD	Tchaconas@mail.cho.org
Infectious Diseases	(510) 428-3336	Ann Petru, MD	APetru@mail.cho.org
International Adoption Clinic at Children's Hospital & Research Center Oakland	(510) 428-3010	Nancy Curtis, MD	Ncurtis@mail.cho.org
Medical Genetics	(510) 428-3885 ext. 2355	John Waterson, PhD, MD	Jwaterson@mail.cho.org
Neonatology/ Intensive Care	(510) 428-3276	Art D'harlingue, MD	Adharlingue@mail.cho.org
Neonatal Follow-up Program	(510) 428-3885 ext. 2299	Veronica Daly, MD	Vdaly@mail.cho.org
Nephrology	(510) 428-3335	Barbara Botelho, MD	Bbotelho@mail.cho.org
Neurology	(510) 428-3885 ext. 2912	Daniel Birnbaum, MD	Dbirnbaum@mail.cho.org
Neuropsychology Assessment	(510) 428-3885 ext. 2912	Daniel Birnbaum, MD	Dbirnbaum@mail.cho.org
Neurosurgery	(510) 428-3319	Peter Sun, MD	Psun@mail.cho.org
Ophthalmology	(510) 428-3050	Selim T. Koseoglu, MD	Skoseoglu@mail.cho.org
Orthopaedics	(510) 428-3238	Colleen Sabatini, MD	Csabatini@mail.cho.org
Otorhinolaryngology	(510) 428-3456	Robert Wesman, MD	Rwesman@mail.cho.org
Pathology & Clinical Lab Medicine	(510) 428-3530	Jon M. Rowland, MD, PhD	Jrowland@mail.cho.org
Plastic Surgery	(510) 428-3024	Chau Tai, MD	dr.Ctai@mail.cho.org
Primary Care Center	(510) 428-3129	Patricia Chase, MD	Pchase@mail.cho.org
Psychiatry	(510) 428-3354	Andrew Giammona, MD	Agiammona@mail.cho.org
Pulmonary Medicine	(510) 428-3305	Karen Hardy, MD	Khardy@mail.cho.org
Rehabilitation Medicine	(510) 428-3655	Christine Aguilar, MD	Caguilar@mail.cho.org
Sleep lab	(510) 428-3305	Karen Hardy, MD	Khardy@mail.cho.org
Surgery	(510) 428-3022	Wolfgang Stehr, MD	Wstehr@mail.cho.org
Synagis Clinic	(510) 428-3885, ext. 2914	Karen Webb, NP	Kwebb@mail.cho.org
Trauma Center	(510) 428-3022	Christopher Newton, MD, FACS	Cnewton@mail.cho.org
Urgent Care	(510) 428-3259	Augusta Saulys, MD	Asaulys@mail.cho.org
Urology	(510) 848-1727	Laurence Baskin, MD	Lbaskin@mail.cho.org