Referral

from Physician

Thank you for working with Solace Pediatric Healthcare. We look forward to providing the best possible service to you and your families. We are dedicated to working with our referral partners so you rest assured that you will receive immediate attention and the answers that you need right away.

How to Refer Your Patient:

  • Option 1:  Complete the referral form below and upload the required medical records (including ICD-10, allergies and medications, order for evaluation and visit note)
  • Option 2: Complete referring information for contact and upload your office referral form and required medical records (including ICD-10, allergies and medications, order for evaluation and visit note)
  • Option 3: Fax your referral form and required medical records (including ICD-10, allergies and medications, order for evaluation and visit note).

Process for Referrals:

  • Complete our Referral Form and attach required medical records by one of the options listed above
  • Once we receive the referral, we will respond to you within 48 business hours to confirm the patient qualifies for services
  • Private Insurance and/or Medicaid will be verified
  • Our staff will schedule an initial evaluation with the Parent/Caregiver
  • The evaluating Therapist will recommend frequency of services and schedule visits
  • Therapy services will begin after the Physician signs the plan of care and authorization is received from insurance company and/or Medicaid

If you are affiliated with a physician’s office and would like to submit a referral, along with medical records (including ICD-10, allergies and medications, order for evaluation and visit note), please complete the form below.

Referral Form

*Denotes mandatory field

Referral Physician
Gender

What services are needed?

Home Address
Home Address
City
State/Province
Zip/Postal

Primary Insurance

Is the patient currently receiving therapy for the concerns listed in this referral?
If yes, where are they receiving therapy?
Required for therapy evaluation Order

  • Visit Note discussing therapy
  • Medical history (Include ICD-10, allergies, meds
  • Physician order (Include evaluation order is valid
  • for 30 days, signed by physician)
Maximum upload size: 516MB
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