Referral Request for a Child

(For established patients seen within the last 12 months only / For non-emergency/non-urgent matters)

Having a medical concern or new symptom or illness can be emotionally difficult and challenging for any patient. Sometimes a specialist services or additional testing outside of our practice are needed. It is our goal to help every client to the best of our abilities. As we care for thousands of patients, please work with us to prioritize and provide care for you efficiently. In order to manage your health concern or referral request please review the guide below and provide us with relevant information about your condition and any questions you may have.

If you are having an emergency ( have sudden visual, hearing, muscle or other loss of function, can’t breathe, have chest pain or have any sudden changes in your health), please call 911 or go to the nearest emergency room.

If you are not having an emergency, please consider one of the following:

  • If you are sick and needs to be seen please make an Make an appointment It is our preference that if you are sick and require medical attention, please select the next available appointment regardless of the doctor or the location to provide you with timely evaluation.)
  • If you are sick but you wish to consult the doctor electronically or need an urgent appointment which may not be available, please help our doctors appropriately triage your situation by submitting a detailed consultation request below.
  • If you wish a referral to a specialist , for medical test or specialized therapy, please help our doctors appropriately address your need and assist you by submitting a detailed specialist/test/therapy referral request below.

    First name (*) :

    Last name (*) :

    Your Email (*) :

    Your DOB (*) :

    Your phone number (*) :

    Type of request (*) :

    Please provide the details of your reasons for the referral request:

    Please provide the information about the referral you need:

    Name of the Provider or the Facility (*) :

    Phone number of the Provider or the Facility (*) :

    Fax number of the Provider or the Facility (*) :

    Name of the insurance/ health plan you currently have and require the referral for (*) :

    Provider’s insurance ID – ( knows as provider ID) of the plan under which you wish the referral (*) :

    Address or website / link of the Provider or the facility

    If you wish, please upload a file or image of any details about the referral (pdf/jpg-Max size 5MB) :


    Please select the doctor whom you wish to send your request (*) :

    Select a mode of delivery:

    Select the urgency (*) :

    Please select the level of urgency for your request:

    Medium - semi urgent – wish response within 24 hours-one business day (Mo-Fri 9am-5pm)Low - not urgent - wish response within 72 hours (Mo-Fri 9am-5pm)

    Electronic Medical Consultations (Telehealth Services)
    Consents, Confidentiality and Financial Policy

    Bodhi Medical Group and Apple Pediatrics are pleased to offer our patients electronic access to our healthcare services, including telephone and email consultations and virtual “telehealth” office visits via simultaneous audio and video transmissions through services such as Skype or FaceTime. These services, which we are calling collectively our “telehealth” services, are actual medical services and, as such, our team is committed to providing the same high quality healthcare as we do when our patients visit our offices in person. Although you have selected to use one of our telehealth services, either for your own care or on behalf of your child, please know that you always have the option of visiting our offices directly. You may make appointments for in office, face-to-face medical visits online, 24/7 at www.mybodhi.com, or you may call us toll free at (888) 603-0933 for pediatric services and (888) 603-9338 for adult services.
    Before we can provide telehealth services to you or your child, you must review and acknowledge that you understand the following information concerning your rights and responsibilities and consent to the conditions related to data security and our financial policy.
    I. Consent for Care. Bodhi Medical Group and Apple Pediatrics offer telehealth services through a variety of electronic means, including telephone, email, and simultaneous audio and visual transmission using services such as Skype or FaceTime when available. Our telehealth services may include medical evaluation, medical consultation, diagnosis, referral to a specialist, and medication management and refill approvals.

    • I understand that, while I may benefit from the convenience of accessing healthcare electronically, Bodhi Medical Group and Apple Pediatrics do not guarantee any cure, improvement or success of any medical advice and may recommend that I or my child seek face-to-face consultation either with Bodhi Medical Group and Apple Pediatrics or another medical provider or medical facility

    • I understand that it is my duty to provide complete and accurate information about my or my child’s health condition and history and that my failure to do so may result in the provision of incomplete, inaccurate or inappropriate evaluation, diagnosis, and treatment.

    II. Authorization to Share Information Electronically. Bodhi Medical Group and Apple Pediatrics are committed to using electronic systems that incorporate network and software security protocols to protect the confidentiality of patient information and safeguard data against intentional or unintentional corruption.

    • I authorize the sharing of my or my child’s health information electronically for the provision of telehealth services and related activities, such as appointment reminders and on-going medical management

    • I understand that there are potential risks associated with the provision of telehealth services. For example, delays in the provision of telehealth services could occur due to deficiencies or failures of equipment, or security protocols could fail, causing a breach of privacy of personal medical information.

    • I also understand that I am solely responsible for the selection of the electronic device(s) (for example, smart phones, computer tablets and computer laptops and desktops) and their related systems (hardware, software, firewalls, encryption features, network service providers or other electronic equipment features) I use in requesting telehealth services. I agree to indemnify and hold harmless Bodhi Medical Group and Apple Pediatrics, their agents and representatives, for any failure of the selected device(s) and their related systems as well as for the loss, theft or exposure of protected health information from my electronic device(s) and their related systems, whether or not such failure or losses are intentional.

    III. Notice of Privacy Practices. The Notice of Privacy Practices explains how medical information about you or your child may be used and disclosed, your rights concerning this information, and instructions on how you can access this information. Please review the notice by clicking on the following link: http://www.mybodhi.com/noticeofprivacypractices.pdf

    • I acknowledge that I have received, read, and have had the opportunity to ask questions about the Notice of Privacy Practices.

    IV. Consent for Release of Information and Assignment of Benefits. Bodhi Medical Group and Apple Pediatrics may share health information for operational purposes, most regularly to bill insurance companies for healthcare services, including telehealth services.

    • I authorize this practice to give information related to my visit to my insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to Bodhi Medical Group and Apple Pediatrics. I further consent to the use of this information for other healthcare operations conducted by our practice, as identified in the Notice of Privacy Practices

    V. Financial Policy. We appreciate you choosing Bodhi Medical Group and Apple Pediatrics for your healthcare. So that we may consistently deliver high quality care and services, we ask you to adhere to the following financial policies:

    • I am responsible for all co-payments, amounts applied to deductibles, and other amounts that may be deemed my responsibility by my insurance carrier(s) or other payment sources whether care is provided to me or to my child.

    • I understand that my insurance carrier(s) may or may not cover some services and that I am solely responsible for charges not reimbursed by my insurance carrier(s) for care provided to me or my child.

    • I understand that not all insurance policies are the same and that it is my responsibility to verify applicable coverage prior to receiving services.

    • If these telehealth services are not covered by my or my child’s insurance, I agree to pay for these services according the following schedule:

    Telehealth Service

    Fee

    Telephone Consultation

    $10 per call

    Email Consultation

    $10 for each ten (10) minutes of provider’s emailing time

    Audio-Visual Consultation

    $30 for the first ten (10) minutes; $25 for each additional fifteen (15) minute increment

    On-line or Telephone Medication Management (including new medications, adjustments, refills)
    (No controlled substance management is offered via this service)

    $5 per request

    • I authorize Bodhi Medical Group and Apple Pediatrics to bill the credit card on file for services not covered by my insurance carrier(s).

    I have read and understand the acknowledgements, consents and financial policies stated above and agree to accept full responsibility for complying with them.

    Please sign your request (*) :

    (*) Required fields

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