Cedar f
ormulario de referencia
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Información de referencia
Origen del referido
Fecha de referido
Teléfono
Correo electronico
¿Los padres o tutores legal están consciente y totalmente de acuerdo con este referido?
Sí
No
Información del padre 1
Nombre del Padre/Guardián
Apellido
del Padre/Guardián
Teléfono de casa
Teléfono móvil
Correo electronico
¿Necesita intérprete?
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Sí
No
Si necesita interprete, ¿cuál idioma?
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Arabic
ASL
Chinese
Creole
English
French
Fulani
Hmong
Italian
Khmer (Cambodian)
Kʼicheʼ
Laotian
Portuguese
Russian
Spanish
Swahili
Turkish
Unknown
Urdu
Vietnamese
Wolof
Información del padre 2
Nombre del Padre/Guardián
Apellido
del Padre/Guardián
Teléfono de casa
Teléfono móvil
Correo electronico
¿Necesita intérprete?
Seleccione por favor
Sí
No
Si necesita interprete, ¿cuál idioma?
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Arabic
ASL
Chinese
Creole
English
French
Fulani
Hmong
Italian
Khmer (Cambodian)
Kʼicheʼ
Laotian
Portuguese
Russian
Spanish
Swahili
Turkish
Unknown
Urdu
Vietnamese
Wolof
Child Information
Nombre de pila
Inicial del segundo nombre:
Apellido
Fecha de nacimiento
Género:
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Femenino
Masculino
Transgénero
Hombre trans
Mujer trans
No binario
Prefiero no responder
Otro
El número de seguro social del niño y/o la información de identificación de Medicaid DEBEN incluirse para enviar el formulario.
Número de seguro social del niño
Número de identificación de Medicaid
Número de 10 dígitos, localizado en la tarjeta ancla del niño
Dirección (la calle y el numero)
Ciudad
Estado
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Código postal
Nombre del médico de atención primaria
Teléfono
Seguro médico primario
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BCBS RI
United
NHPRI (other than Integrity)
NHPRI (Integrity for Duals)
Tufts
No Carrier
Other
Unknown
ID de miembro del seguro primario
Seguro médico secundario
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BCBS RI
United
NHPRI (other than Integrity)
NHPRI (Integrity for Duals)
Tufts
No Carrier
Other
Unknown
ID de miembro del seguro secundario
¿Niño inscrito en atención actual?
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Si
No
Códigos DX médicos (si se conocen)
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B08.4 Enteroviral vesicular stomatitis with exanthem
C91.00 Acute lymphoblastic leukemia not having achieved remission
D50.9 Iron deficiency anemia
D57.1 Sickle-cell disease without crisis
D68.1 for Hereditary factor XI
E10.9: Type 1 diabetes mellitus without complications
E11. 9 Type 2 diabetes mellitus Without complications
E23.3, Hypothalamic dysfunction
E27.0 Other adrenocortical overactivity
E27.49 - Other adrenocortical insufficiency
E63.9 Nutritional deficiency, unspecified
E66.01 Morbid (severe) obesity
E66.3 Overweight
E66.9 obesity, unspecified
E75.242 Niemann-Pick disease type C
F06.4 Anxiety disorder due to known physiological condition
F29 - Unspecified psychosis not due to a substance or known physiological condition
F31.9 Bipolar disorder, unspecified
F32.0 Major Depressive disorder, single episode
F32.2 · Major depressive disorder, single episode, severe without psychotic features
F32.4 – Major Depressive disorder, single episode
F32.8 – Other depressive episodes
F32.9 Major Depressive Disorder
F33.2 · Major depressive disorder, recurrent severe without psychotic features
F33.3 Major depressive disorder
F33.9 Major depressive disorder, recurrent, unspecified
F34.81 Disruptive mood dysregulation disorder
F34.8 Disruptive mood dysreg. disord.
F39 Unspecified mood [affective] disorder
F40.10 · Social phobia, unspecified
F41.0 Panic disorder
F41.1 Generalized anxiety disorder
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
F42.9 Obsessive-Compulsive Disorder, unspecified
F43.10 Post-traumatic stress disorder
F43.20 Adjustment disorder, unspecif.
F43.21 Adjustment disorder with depressed mood
F43.22 Adjustment disorder with anxiety
F43.24 Adjustment disorder with disturbance of conduct
F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
F43.29 Adjustment disorder with other symptoms
F48.9 Self-injurious behavior
F50.89 – Other specified eating disorder
F51.02 Adjustment insomnia
F70 Mild intellectual disabilities
F71 Moderate intellectual disability
F72 Severe intellectual disabilities
F78 Other intellectual disabilities
F79 Unspecified intellectual disabil.
F80.1 Expressive language disorder
F80.2 Mix receptive-expressive lang.
F80.4 – Speech and language developmental delay due to hearing loss
F80.81 Childhood-onset fluency disorder
F80.82 - Social pragmatic communication disorder
F80.89 Other dev. dis. speech/lang.
F80.9 Dev. dis. speech/lang. unspec.
F81.0 Specific reading disorder
F81.2 Mathematics disorder
F82 Spec. dev. disor. of motor func.
F84.0 Autistic disorder
F84.5 Asperger's syndrome
F84.8 Other pervasive dev. disorders
F84.9 Pervasive dev. disor., unspec.
F88 Other disord. of psychol. dev.
F89 Unspeci. disor. of psychol. dev.
F90.0 ADHD, inattentive type
F90.1 ADHD, hyperactive type
F90.2 ADHD, combined type
F90.8 Attention-deficit hyperactivity disorder, other type
F90.9 ADHD, unspecified type
F91.1 Conduct disorder
F91.3 Oppositional defiant disorder
F91.8 Other conduct disorders
F91.9 Conduct disorder, unspecified
F93.8 - Other Childhood emotional disorders
F93.9 Childhood emotional disorder, unspecified
F93 Emotional disorders with onset specific to childhood
F94.0 Selective mutism
F94.9 Childhood disorder of social functioning, unspecified
F95.2 – Tourette’s disorder
F95.9 Tic disorder, unspecified
F98.0 – Enuresis not due to a substance or known
F98.4 Steroetyped movement disorders
F98.8 Other speci. behavior/emotion
F98.9 – Unspecified Behavioral and emotional disorder
G04.90 Encephalitis and encephalomyelitis, unspecified
G11.3 Cerebellar ataxia with defective DNA repair
G25.3 Myoclonus
G31.82 - Leigh’s Disease
G31.9 Cerebral atrophy
G40.219 Localization-related symptomatic epilepsy and epileptic syndromes with partial seizures
G40.309 General idiopathic epileptic
G40.409 Other generalized epilepsy and epileptic syndromes
G40.409 Other generalized epileptic
G40.802 Other epilepsy,
G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.834 Dravet syndrome, intractable, without status epilepticus
G40.89 amelo-cerebro-hypohidrotic syndrome
G40.901 Epilepsy, unspecified, not intractable, with status epilepticus
G40.909 Epilepsy, unspecified
G47.00 Insomnia, unspecified
G47.30 Sleep apnea, unspecified
G47.9 Sleep disorder, unspecified
G60.0 Hereditary motor and sensory neuropathy
G71.01 - Duchenne Muscular Dystrophy
G80.0 - Spastic quadriplegic cerebral palsy
G80.1 Spastic diplegic cerebral palsy
G80.4 Ataxic cerebral palsy
G80.8 Other cerebral palsy
G80.9 Cerebral palsy, unspecified
G89.29 Other chronic pain
G89.4 Chronic pain syndrome
G90.9-Disorder of the autonomic nervous system, unspecified
G91.9 Hydrocephalus, unspecified
G93.0 Cerebral cysts
G93.1 Anoxic brain damage, not elsewhere classified
G93.5 Compression of brain
G98.8 - Other disorders of nervous system
H47.031 Optic nerve hypoplasi, right
H47.032 Optic nerve hypoplasia, left
H50.00 Estropia
H50.10 Unspecified exotropia
H50.51 – Esophoria
H50.89 Other specified strabismus
H52.1 Myopia
H53.9 Unspecified visual disturbance
H90.0 - Conductive hearing loss, bilateral
H90.3 Sensorineural hearing loss, bilateral
H90.5 – Unspecified sensorineural hearing loss
H91.8X2 – Other specified hearing loss, left ear
H91.90 - Unspecified hearing loss, unspecified ear
H91.93 Unspecified hearing loss, bilateral
I60.9 Nontraumatic subarachnoid hemorrhage, unspecified
I61.5 Nontraumatic intracerebral hemorrhage, intraventricular
I61.9 Nontraumatic intracerebral hemorrhage, unspecified
I67.8 - Other specified cerebrovascular diseases
J35.1 Hypertrophy of tonsils
J44.909 Chronic obstructive pulmonary disease, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.30 Mild persistent asthma, uncomplicated
J45.40 moderate persistent asthma, unspecified
J45.901 Unspe. asthma w/exacerbation
J45.909 Unsp. asthma, uncomplicated
J96.10 Chronic respiratory failure, uns.
J98.01 Acute bronchospasm
K21.0 Gastro-esophageal reflux disease with esophagitis
K21.9 Gastro-esophageal reflux disease without esophagitis
K59.09 Other constipation
K59.0 for Constipation
K91.2 Postsurgical malabsorption
L20.84 Intrinsic (allergic) eczema
L30.9 Dermatitis, unspecified
L81.4 Other melanin hyperpigmentation
M08.80 Other juvenile arthritis, unspecified site
M21.969 – Unspecified acquired deformity of unspecified lower leg
M26.09 Other specified anomalies of jaw size
M41.26 Other idiopathic scoliosis, lumbar region
M48.10 Ankylosing hyperostosis [Forestier], site unspecified
M62.81 Muscle weakness (generalized)
M89.9 Disorder of bone, unspecified
N39.44 Nocturnal enuresis
Other
P05.18 Newborn small for gestational age, 2000-2499 grams
P91.2 - Neonatal cerebral leukomalacia
P91.60 – hypoxic ischemic encephalopathy
P92.6 Failure to thrive in newborn
Q02 Microcephaly
Q04.0 Cong. malform. corpus callosum
Q05.1 Thoracic spina bifida with hydrocephalus
Q05.9 Spina bifida, unspecified
Q06.1 Hypoplasia and dysplasia of spinal cord
Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus
Q15.8 Norrie's disease
Q21.0 Ventricular septal defect
Q21.2 Atrioventricular septal defect
Q23.1 Congenital insufficiency of aortic valve
Q24. 8 - Other specified congenital malformations of heart
Q38.1 Ankyloglossia
Q43.1 Hirschsprung's disease
Q54.1: hypospadias, penile
Q54.9 Hypospadias, unspecified
Q65.4 - Congenital partial dislocation of hip
Q65.89 Other specified congenital deformities of hip
Q66.0 – Congenital Talipes emquinovarus
Q66.0 Congenital talipes equinovarus
Q67.3 Plagiocephaly
Q68.1 Congenital deformity of finger(s) and hand
Q74.3 Arthrogryposis multiplex congenita
Q75.3 Macrocephaly
Q79.3 Gastroschisis
Q85.8 Other phakomatoses
Q87.1 Cong. malf. syn. short stature
Q87.2 Cong. malf. syn. involve limbs
Q87.89 Other specified congenital malformation syndromes, not elsewhere specified
Q89.8 - Other specified congenital malformations
Q90.0 Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q90.1 Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.9 Down syndrome, unspecified
Q93.5 Angelman syndrome
Q93.81 Velo-cardio-facial syndrome
Q93.88: Other microdeletions
Q98.4 Klinefelter syndrome, unspecified
Q99.2 Fragile X chromosome
Q99.9 Chromosomal abnormality, unspecified
R01.1 Cardiac murmur, unspecified ·
R10.84 – Generalized abdominal pain
R13.10 Dysphagia, unspecified
R13.12 Dysphagia, oropharyngeal phase
R15.9 Full incontinence of feces
R25.1 Tremor, unspecified
R26.9, Unspecified abnormalities of gait and mobility
R27.9 Unspecified lack of coordination
R29.898 - Other symptoms and signs involving the musculoskeletal system
R30.0 Dysuria
R40.4, Transient alteration of awareness
R41.83 Borderline Intellectual Functioning
R41.840 – Attention and Concentration Deficit
R41.84 Other Specified Cognitive Delay
R41.89 Other symptoms and signs involving cognitive functions and awareness
R44.0 Auditory hallucinations
R45.851 Suicidal ideations
R45.86 Emotional lability
R46.2 Strange/Inexplicable Behavior
R46.89 Other symptoms and signs involving appearance and behavior
R47.9 Unspecified speech disturbances
R48.2 Apraxia
R52 Pain, unspecified
R56.9 Unspecified convulsions
R62.0 Delayed milestone in childhood
R62.50 Unspecif. lack physiolo. dev.
R62.51 Failure to thrive
R62.59 Other lack of expected normal physiological development in childhood
R62.5 Other and unspecified lack of expected normal physiological development in childhood
R63.3 Feeding difficulties
R63.4 Abnormal weight loss
R63.5 Abnormal weight gain
R68.11 Excessive crying of infant (baby)
R68.89 Other general symptoms
R70 Elev. erythr. sedimentation rate
R73.03 Prediabetes
S09.8 Other specified injuries of head
T14.91XD Suicide attempt, subsequent encounter
Z00.129 Encounter for routine child health examination without abnormal findings
Z04.9 Observation for suspected condition Red Flags for ASD
Z13.42 - Encounter for screening for global developmental delays (milestones)
Z55.9 Problems related to education and literacy, unspecified
Z60.8 Other problems related to social environment
Z60.9 Problem related to social environment, unspecified
Z62.822 Parent-foster child conflict
Z62.9 Ineffective parenting skills
Z63.5 Disruption of family by separation and divorce
Z63.79 Stress life event affect fam.
Z68.21 Body mass index [BMI] 21.0-21.9, adult
Z68.52 BMI pediatric, 5th percentile to less than 85th percentile for age
Z68.53 At risk for overweight, pediatric, BMI 85-94% for age
Z68.54 · Body mass index [BMI] pediatric, greater than or equal to 95th percentile for age
Z71.3 Dietary counseling and surveillance
Z71.89 Other specified counseling
Z73.819 Behavioral insomnia, unspec.
Z74.09 Other reduced mobility
Z76.89 Sleep concern
Z81.8 Family history of other mental and behavioral disorders
Z82.2 Family history of deafness and hearing loss
Z86.59 Personal history of other mental and behavioral disorders
Z91.018 Allergy to other foods
Z93.1 Gastrostomy status
Z93.2 Ileostomy status
Z94.1 Heart Transplant Status
Z96.22 Myringotomy tube(s) status
Z99.11 Dependence on respirator [ventilator] status
Z99.3 Dependence on wheelchair
Mantenga presionada la tecla Mayús para seleccionar múltiples opciones.
Condiciones crónicas que requieren coordinación de cuidados intensivos (marque todos los que apliquen)
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Trastorno por déficit de atención e hiperactividad
Alzheimer/Demencia
Ansiedad
Artritis
Asma
Trastorno del espectro autista
Problemas de comportamiento
Problemas de huesos, articulaciones o músculos
Lesión cerebral
Paciente con cáncer
Sobreviviente de cáncer
Parálisis cerebral
EPOC (Enfermedad Pulmonar Obstructiva Crónica)
Depresión
Retraso en el desarrollo
Diabetes
Síndrome de Down
Epilepsia
Riesgo de caídas
Hígado graso
Fibromialgia
Problemas de audición
Enfermedad cardíaca
Colesterol alto
Hipertensión
Discapacidad intelectual
Enfermedad renal
Dificultad de aprendizaje
Entrada manual
Manejo de la terapia con medicamentos
Salud mental
Necesidades no médicas
Asesoramiento nutricional/Alimentación saludable
Obesidad
Trastorno Obsesivo-Compulsivo o TOC
Osteoporosis
Otro (por favor especifique)
Dolor
Prediabetes
Esquizofrenia u otro trastorno psicótico
Trastorno convulsivo
Anemia de células falciformes
Problemas del habla
Derrame cerebral/Accidente cerebrovascular
Uso de tabaco
Síndrome de Tourette
Problemas de visión
Control de peso
Jóvenes con necesidades especiales
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Factores de riesgo del niño o de la familia
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2+ visitas al departamento de emergencias en los últimos 12 meses (Conductual)
2+ visitas al departamento de emergencias en los últimos 12 meses (Médico)
2+ ingresos a salud conductual en los últimos 12 meses
2+ ingresos médicos en los últimos 12 meses
Hospitalización/Ingreso actual
Dificultades con las actividades de la vida diaria
Dificultad para asistir a citas
Violencia doméstica
Inseguridad alimentaria
Problemas de vivienda
Otro (debe especificar)
Preocupaciones de salud mental o retraso cognitivo del padre/tutor
Problemas escolares (bajo rendimiento académico, ausentismo, comportamiento)
Consumo de sustancias - Tutor
Consumo de sustancias - Niño
Consumo de sustancias - Padre/Madre
Trauma
Incapaz de participar en actividades sociales
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Especificar otra
No se enviará una referencia sin el número de seguro social o la identificación de Medicaid del niño. Asegúrese de que sea exacto antes de enviarlo.
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