HPP MRC External Nomination Log

HPP MRC External Nomination Log

Provider Name*

Date*

Institution*

Email*

Phone Number*

Patient Name*

Patient Date of Birth*

Patient Phone Number

Patient E-mail

Summary of Clinical Symptoms

Records

Please include the following, if possible: - Signed medical release form - Skeletal survey, fractures/pseudofractures images, rickets survey, or DXA. Upload images directly to us via this link- https://hppmrc.ambrahealth.com/share/hppmrc - Labs (CMP showing low ALP, Phosphorus, B6 and/or PEA) -Molecular Testing -Most recent clinic note/ medical history

Drag and drop files here or

Help

Please contact Kemi Lewis with any submission questions- kjlewis@cmh.edu or 816-302-8419

Send me a copy of my responses

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