Get the free CSHCS LHD Referral Form. CSHCS LHD Referral Form

Family Center Referral Form Family Center for Children and Youth with Special Health Care Needs 320 S Walnut Street 6TH Floor Lansing, MI 48913 Fax 5172418970 Family Phone Line 18003593722 www.michigan.gov/cshcs

How to fill out cshcs lhd referral form

How to fill out cshcs lhd referral form

1. Start by obtaining a copy of the CSHCS LHD referral form.
2. Fill in the requested information in the 'Patient Information' section. This may include the patient's name, date of birth, address, and contact details.
3. Provide details about the patient's medical condition or reason for referral in the 'Reason for Referral' section. Be as specific as possible to ensure accurate assessment and appropriate care.
4. If applicable, include any supporting documentation or medical reports that can help in the evaluation process.
5. Complete the 'Referring Physician Information' section with the details of the referring physician, including their name, contact information, and medical license number.
6. Review the completed form to ensure all fields are filled correctly and all necessary information is provided.
7. Sign and date the form to certify its accuracy and completeness.
8. Submit the filled-out form to the appropriate recipient or healthcare provider according to the specific instructions provided.

Who needs cshcs lhd referral form?

1. The CSHCS LHD referral form is typically needed by healthcare professionals or referring physicians who wish to refer a patient to the Children's Special Health Care Services (CSHCS) Local Health Department (LHD) for specialized care or assessment.
2. It may also be required by the CSHCS program itself to initiate the referral process and ensure proper coordination of services for eligible children with special health care needs.

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