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PATCH Provider Referral Form

Thank you for your interest in referring your patient to PATCH (Patient Assistance Team at Children’s Hospital & Medical Center). Please submit this HIPAA compliant form and a member of our Child Live Services team will reach out to the parent/guardian to create the Adaptive Care Plan. We will also keep you informed of the status of the referral.

  • Patient Information

  • MM slash DD slash YYYY

  • Referring Physician/Practitioner Information

  • Referral Information

Contact Us

For general questions or feedback, you can send an email to [email protected], reach out to the PATCH Program Coordinator [email protected]; or call 402-955-5400 and ask to speak Dr. Patricia Sullivan in Behavioral Health.

For questions regarding a specific PATCH patient or Adaptive Care Plan contact Child Life Specialist, Rob Harding, [email protected] 402-955-3594; or Child Life Supervisor, Nikki Walker, [email protected], 402-955-5322.


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