International Patient Program. Referral Form

Transcription

1 L M VII UMBR D O BIRH X DDR IMRI OR R DIL BY HD lease complete this form in GLIH only. ections 1 to 7 must be completed I ULL and signed by the patient s arent/legal Guardian. IO 1: I IORMIO Last ame irst ame : Date of Birth () of Birth Gender Language(s) poken at Home I Male emale Other I mail ddress Middle ame of itizenship nglish Interpreter eeded? Yes o Diagnosis omments on atient s ondition urpose of Referral elehealth onsultation Medical econd Opinion ssessment/onsultation Medical/urgical reatment Method of payment for healthcare services at he Hospital for ick hildren Insurance elf-ay mbassy or hird arty Organization pplying for assistance through the Herbie und IO 2: R/LGL GURDI IORMIO ame of arent/legal Guardian 1 Relationship to atient (e.g. arent) -mail ddress ame of arent/legal Guardian 2 Relationship to atient (e.g. arent) -mail ddress Work hone Work hone Who is the primary contact for this patient? arent/legal Guardian 1 arent/legal Guardian 2 Other (lease pecify) of rimary ontact ame as atient ddress mail ddress age 1 of 3

2 L M VII UMBR D O BIRH X DDR IMRI OR R DIL BY HD IO 3: IIL BKGROUD IORMIO he Hospital for ick hildren reserves the right to request any of the following financial documentation as part of the application/referral process: letter from the employer(s) confirming employment and annual salary for the employed parent(s) opies of income tax filings for the past two (2) years tatements verifying bank account balances arent/legal Guardian 1 Occupation How Long in urrent osition : I I mployer ompany ame of arent/legal Guardian 1 arent/legal Guardian 1 mployer ontact ame and elephone # arent/legal Guardian 2 Occupation How Long in urrent osition mployer ompany ame of arent/legal Guardian 2 arent/legal Guardian 2 mployer ontact ame and elephone # rincipal Income arner? Other (lease specify) ather Mother amily s nnual Income in $UD umber of Dependents in amily IO 4: YM IORMIO lease indicate who will be financially responsible for payment. heck the appropriate box and provide all details. Insurance ame of Insurance ompany olicy umber olicy Holder Group umber Maximum overage mount in $UD Business ddress hird arty dministrator (if applicable) elephone elf-ay (lease provide information on the person who will be financially responsible for payment.) Last ame irst ame Initial Relationship to atient elephone # ax # -mail ddress mbassy or hird arty Organization (Written guarantee of responsibility for payment will be required.) ame of mbassy or hird arty Organization and Key ontact Information Business ddress elephone # ax # -mail ddress his is an application for Herbie unding ssistance O: he Herbie und assists children from developing countries to receive surgical treatment, which is not readily available in their home region, at he Hospital for ick hildren. he Herbie und has specific criteria and guidelines for surgical treatments that are eligible for funding, and will cover OLY H MDIL O for those treatments who meet the required criteria. ll other costs (e.g. travel, accommodation for family, living costs while in oronto, etc.) are the responsibility of the family. age 2 of 5

3 L M VII UMBR D O BIRH X DDR IMRI OR R DIL BY HD IO 5: DI O IORMIO : I I Do you have a anadian contact? Yes (If yes, please provide details below) o ontact ame Relationship to atient rovince -mail ddress IO 6: RVL IORMIO How will non-medical expenses (e.g. travel, accommodation, daily living expenses, etc.) be paid? IO 7: R/LGL GURDI GRM D IGUR he recommends all medical documentation (e.g. medical reports, scans, X-rays, echo tapes, etc.) be photocopied prior to submitting to he Hospital for ick hildren. If original medical records are submitted, he Hospital for ick hildren is not liable for their loss or damage, or for costs incurred to replace the submitted medical records. lease check appropriate box below. I am submitting original medical documentation. I am submitting photocopied medical documentation. lease print and sign the agreement below. OIRMIO O GRM By signing below, I hereby certify that all information provided and enclosed is true and correct, and submit the medical documentation in full agreement of the above stated terms. ny application containing false information will be considered to be null and void. I agree that upon my child receiving medical clearance from the ickkids medical team, it is expected that we will return to our home country/place of residence abroad. rinted ame of arent/legal Guardian arent/legal Guardian ignature Date () age 3 of 5

4 L M VII UMBR D O BIRH X DDR IMRI OR R DIL BY HD ections 8 to 11 must be OMLD I ULL and IGD by the patient s referring physician. IO 8: RRRIG HYII IORMIO ame of Referring hysician pecialty ame of Referring Hospital ddress of Referring Hospital elephone # ax # -mail ddress he Hospital for ick hildren requires that the patient s referring physician provide documentation to verify that the required assessment, procedure, surgery, treatment and/or specialized medical expertise is not available in the patient s home country or region. IO 9: MDIL UMMRY lease state clinical history and submit all relevant medical information, including: up-to-date (within past 6 months) medical history, diagnosis, height, weight, allergies, vaccinations, results of tests/procedures, medications, and current symptoms. (If the space below is insufficient, please feel free to attach documents). he is unable to accept any supporting medical records obtained more than 6 months prior to submission of this referral to he Hospital for ick hildren. How long has the patient been under your care? What is the patient s primary and/or secondary clinical diagnosis? re there underlying medical conditions to the primary and/or secondary clinical diagnosis? What assessment/treatment is being sought for this patient? What is the reason for referral abroad? What is the urgency of required assessment/treatment? 1-3 months 4-6 months 6-12 months age 4 of 5

5 L M VII UMBR D O BIRH X DDR IMRI OR R DIL BY HD IO 10: OORDIIO O O ORIV/OLLOW U R Is post-operative and/or ongoing follow-up care available and accessible in this patient s home country? Yes o If no, please indicate if the patient will be able to receive post-operative and/or ongoing follow-up care in a neighboring country or region, and provide details. IO 11: RRRIG HYII GRM D IGUR ll international patient referrals must have a responsible physician in the patient s home region who will ensure ongoing care and follow-up once the child is discharged from he Hospital for ick hildren. OIRMIO O GRM By signing below, I am accepting responsibility for (a) providing evidence that all, or a key portion of the required treatment cannot be performed in the atient's country of residence or home region, or is not reasonably accessible to the patient; (b) providing to ickkids an accurate, complete, and current description of atient's condition, including any change in condition from that provided for cost estimate, up to the point of departure from the patient's country of residence; (c) providing or arranging the provision of all post-medical treatment/post-operative and follow up care in a neighbouring country or home region to the patient's home country transfer of care from he Hospital for ick hildren. rint ame of hysician hysician ignature Date () ime (00:00) hysician tamp/eal age 5 of 5