Miami Children's Hospital
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Toll Free: 800-432-6837
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International Patient Registration Form

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If you would like to have your child assessed at Miami Children's Hospital, please complete the Global Health Patient Referral Form below.

Please Note: In order to schedule appointments we first need a fully-completed registration form and all related medical records (including any imaging, laboratory, etc.). Once Global Health receives all relevant information, a coordinator will be assigned to your case to confirm your appointment within a 48-72 hour period.  Be advised that routine appointments are generally scheduled for dates  2-4 weeks after your case has been initiated with a coordinator.  If this is an urgent medical request requiring an appointment within two weeks, please contact Global Health directly at 305-662-8281.



Fields marked with an * are required.


PATIENT INFORMATION
Person requesting assistance (relationship to child):
*



Email *


How did you hear about us? *


Patient Name: *


Birthplace: *


Date of Birth: MM/DD/YYYY *


Age: *


Sex: *



Permanent Address (Country of Origin): *


Permanent City: *


Permanent Country: *


Is this address the same as your billing address *



If not, please provide billing address below
Billing Address



City (Billing Address)


Country (Billing Address)


Phone number in Miami (if available):


Temporary Address or Hotel in Miami (if available):


Mother’s Full Name: *


Mother's Date of Birth: MM/DD/YYYY *


Father’s Full Name: *


Date of Birth: MM/DD/YYYY *


Home Phone Number: *


Office Phone Number:


Cellular Phone Number:


Fax Number:


Referring Physician Name (if applicable):


Specialty:


Telephone:


Referring Physician E-mail:



FINANCIAL INFORMATION

Do you have insurance?
*




Primary Insurance Plan name:


Group Number:


Member Name:


Policy Number:


Group Name:


Please upload copies of the front and back of the insurance card or fax a copies to 305-668-5586


Customer Service Number:


If you are seeking a self-pay discount, please read the disclaimer below and accept: *


Full name of Person Responsible for Bills: *


Medical Information Consent: *



SERVICE REQUESTED

Does your request require immediate attention




Speciality or Service Requested (Select Upto 5)
1.
*



2.


3.


4.


5


Diagnosis / Medical Information *


If you have Medical Records please upload them or fax to: 305-668-5586


Preferred dates to visit:
(Please provide a two week range if possible)
From: MM/DD/YYYY



To : MM/DD/YYYY





Miami Children’s Hospital Global Health Services needs to share your child’s medical information among all physicians and medical personnel required to determine possible treatment and price estimates. Please print and complete the Consent for Release/Request Form  and send it back to Global Health Services along with a copy of a picture ID (such as a Driver's License or Passport). You may fax it directly to 305-668-5586 or email it to globalhealthreferrals@mch.com .