Texas Center for Pediatric and Congenital Heart Disease

The Texas Center for Pediatric and Congenital Heart Disease at Dell Children’s Medical Center offers high-quality, comprehensive pediatric heart care. To avoid any delays in patient care, all clinical documentation must be submitted prior to consultation. Please fax or email all pertinent clinical documentation, including images, to 1-512-380-7532 or DCMCHeartReferrals@ascension.org. Larger files, such as imaging studies, can be uploaded through the iConnect Web Uploader at merge/seton.org/webaccess. For detailed instructions, please visit partnersincare.health/pediatric-cardiology/referral.

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Patient Information

Patient Name

Date of Birth

Guardian Name (If patient is a minor)

Phone (Mobile)

Phone

Phone (Home)

Phone

Primary Care Provider Name

Primary Care Provider Phone Number

Insurance Information

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Insurance Provider Name

Name of Insured Plan Holder

Insurance Group Number

Insurance Group Policy Number

Referring Provider Information

Referring Provider Name

Referring Provider Phone Number

Phone

Referring Provider Fax Number

Phone

Office Staff/Nurse Contact Name

Office Staff/Nurse Phone Number

Phone

Office Staff/Nurse Email

Reason for Referral

Cardiac Diagnosis

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Desired Timing for Consultation

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Surgeon

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Clinical Testing

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Please fax or email all clinical documentation, including images, to 1-512-380-7532 or DCMCHeartReferrals@ascension.org. Larger files, such as imaging studies, can be uploaded through the iConnect Web Uploader at merge/seton.org/webaccess. (For detailed instructions on how to upload your files through iConnect, please visit partnersincare.health/pediatric-cardiology/referral.) You may also choose to mail your clinical documentation to: Texas Center for Pediatric and Congenital Heart Disease 4900 Mueller Blvd., Austin, TX 78723

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Authorization for Release of Medical Records

I hereby authorize any and all medical facilities, providers, and staff to disclose any and all information related to this referral request, including but not limited to, the categories of information listed above. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless any and all medical facilities, providers, and staff from all liability and damages resulting from the lawful release of my child's Protected Health Information (PHI) related to this referral. I am not required to sign this form to receive treatment or healthcare benefits from my health plan. This authorization is voluntary, and I may refuse to sign it. I may request a copy of this signed form. I have read this form and agree to the uses and disclosures of the information as described above. I understand PHI disclosed pursuant to this authorization may be subject to re-disclosure by the person or party it is sent to and may no longer be protected by federal or state privacy laws.

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