Referrals

Please complete the form below to submit a referral.

Please complete this form and submit along with THE MOST RECENT HISTORY AND PHYSICAL

PATIENT INFORMATION

Child's Full Name

Date of Birth

Sex

Male

Female

Address

Insurance/ID#

Diagnosis(es)

ICD Code(s)

Date of Last Visit

PARENT/GUARDIAN INFORMATION

Parent/Guardian

Relationship

Home Phone

Cell Phone

Best Contact

Home

Cell

PROVIDER INFORMATION

Physician/Practice Name

Physician NPI #:

Physician TPI #

Phone

Fax #

Practice Contact:

This referral is made because the patient requires skilled nursing care and may receive that care through a PDHC – Pediatric Day Health Care Center, such as Lauves Pediatric.

The patient is ALSO being referred to be evaluated in the following areas: (Check all that apply)

Physical Therapy

Speech Therapy

Occupational Therapy

Physician Signature

Date

THE MOST RECENT HISTORY AND PHYSICAL

Pediatric Day Health Care Centers (PDHC) allow minors from 6 weeks to 20 years of age with medically complex conditions to receive daily medical care in a non-residential setting.

When prescribed by a physician, minors can attend a PPECC to receive medical services such as nursing, speech therapy, physical therapy, occupational therapy, and developmental services appropriate for their medical condition and developmental status. The minor MUST be stable for outpatient medical services and require ongoing nursing care and other basic needs. Please feel free to contact us at with any questions.

To download the form, click the button below. Once completed, please email it to admin@lauvespediatric.com or deliver it to our office at
2720 Village Ln, Bossier City LA 71112.

Download

Referrals

To download the form, click the button below. Once completed, please email it to admin@lauvespediatric.com or deliver it to our office at 2720 Village Ln, Bossier City LA 71112.

To download the form, click the button below. Once completed, please email it to admin@lauvespediatric.com or deliver it to our office at
2720 Village Ln, Bossier City LA 71112.