ONLINE REFERRAL FORM
Today's Date
Child's First Name
Child's Last Name
Child's Date of Birth (Ex. MM/DD/YYYY)
Child's Medicaid ID
Child's Health Plan
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Parent name
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Name of Person or Physician Referring
Source of Referral
Please Select
Advantage Health Centers
Benejam Clinic
Children's Hospital
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Children's Hospital Audiology
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ClearCorps Detroit
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Detroit Central City
Detroit Community Health Connections
Detroit Riverview
Henry Ford Med Ctr.
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IHA-Family & Internal Med-Cherry Hill
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IHA-Internal Med & Peds-Plymouth
IHA-Ped Healthcare-Canton
Matrix Human Services
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St. Mary Mercy Health System
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Wayne State University Physicians' Group
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Western Wayne Family Health Center
Self-Referral
Other
If your practice or agency is not listed above, please provide name:
Practice or Agency Telephone
Why are you referring to KHC?
Please Select
Asthma
At risk for Dismissal
Child Behavioral Health
ED Usage
Family Needs Reminder Calls
FitFamiles(Healthy Minds)
FitKids 360 (>5 years of age, BMI=>85%)
Frequent No Shows
LENA Start (language enrichment)
Missed Immunizations
Missed Well Child Visits
Needs Transportation
No Insurance
Not Established at the Practice
Other
I certify this child is cleared to participate in FitKids 360
Notes
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