NUTRITION OUTPATIENT REFERRAL FORM - Huntsville
Today’s date and time _____________________
Patient’s name___________________________ Date of birth_______________ Gender: female male
Parent’s name___________________________________________________________________
Parent’s telephone number (home) __________________ (cell) _________________ (work) _______________
Parent’s mailing address___________________________________________________________
Insurance______________________________
Prior authorization complete?  Yes  No
****Parents understand insurance coverage for medical nutrition therapy and accept responsibility for
payment of services not covered by insurance? ****  Yes  No
Patient’s last Weight________________ Height________________ Date recorded_______________
Reason for referral__________________________________________________________________________
_________________________________________________________________________________________
 One Time Evaluation
 Evaluation with Follow Up
ICD-9 Diagnosis Codes are required. Please check all that apply.
 Elevated Glu Tolerance Test
790.2
 Abnormal Wt Loss & Underweight 783.21
 Abnormal Weight Gain
 Allergic Gastroenteritis
 Allergies, Food Related
 Allergy, Milk Protein
 Allergic, Rhinitis due to food
 Anemia, Inadequate Fe Intake
 Anemia, Fe Deficiency, unspec
 Anemia, Nutritional
783.1
558.3
693.1
558.3
477.1
280.1
280.9
281.8

783.0

307.1
 Asthma, unspec
 Celiac Disease
 Cerebral Palsy, infantile unspec
 Cleft Lip & Palate, unspec
 Congenital Heart Disease
 Constipation
579.0
343.9
749.2
746.89
564.0
Diabetes type I, not uncontrolled
250.01
 Diabetes type I, uncontrolled 250.03
 Diabetes type II, not uncontrolled
250.00
 Diabetes type II, uncontrolled 250.02
 Diarrhea, NOS
787.91
 Dysphagia/Swallowing diff
787.20

783.41
 Feeding Difficulty – Infant
783.3
 Food Refusal/Rejection
307.59
 GERD
530.81
 Hypercholesterolemia
272.0
 Hypertriglyceridemia
272.1
 Hyperinsulinism
251.1
 Hyperlipidemia, NOS
272.4
 Hypertension
401
 Hypoglycemia
251.2
 Joint disorder /walking diff

alnutrition, moderate
263.0
 Malnutrition, mild
719.9
263.1

278.01
 Nutritional Deficiency, unspec

/Overweight
278
 Excessive Eating/Polyphagia

, NOS
765.10
 Protein-losing Enteropathy
 Short Stature
 Sleep Apnea, unspec
Underweight
 _______________________
 _______________________
 _______________________
 _______________________
 _______________________
269.9
783.6
579.8
783.43
780.57
783.22
______
______
______
______
______
Medical History includes (list all past medical problems/diagnoses)___________________________
_________________________________________________________________________________
_________________________________________________________________________________
MD Signature (required)_____________________________ Print MD name___________________
Telephone________________________________________ Fax____________________________
Contact Person____________________________________
***Patients will not be contacted to schedule appointment until all pertinent medical information is received. ***
Please fax completed form, growth chart, last clinic note, and all pertinent labs/med list to (205) 939-6047. For more information,
please call our office (205) 939-9204.
****** (Please DO NOT fax without MD signature) ******
TO BE COMPLETED BY CLINICAL NUTRITION DEPT:
Appointment date/time: _______________________
Location:  Children’s Park Place 2
 North Alabama Children’s Specialists
 Children’s South
Clinician: _________________________________
Refused outpatient nutrition consultation
 Cancelled appointment without rescheduling
No show for appointment
Unsuccessful x 3 attempts to contact caregiver
_______________________________________________
Updated July 13, 2009
Beeper #: _________________________________
Rescheduled appointment: _________________________ 
Updated July 13, 2009