Physician Referral Form for Autism Spectrum Disorder Screening

Instructions

Detroit Wayne Integrated Health Network's (DWIHN) Access Call Center provides information on an array of services and supports for eligible persons with serious mental illness, serious emotional disturbance, substance use disorders, and/or intellectual/developmental disabilities. There is no "wrong door" for access to people with any of these disorders. A child or adolescent requiring further evaluation to assess for autism spectrum disorder (ASD) or to enroll in Michigan Medicaid Autism Services (i.e., ABA services) may call 1-800-241-4949 or provide a physician referral. If providing a physician referral please include the date of the last full medical & physical examination, member name, birth date, contact information, referring agency contact information, NPI number, and upload the results of a validated ASD screening tool. The screening tool may be completed by the parent/guardian and reviewed/verified by the physician. The form will not be processed by DWIHN if information is not accurate or included as requested. The physician will submit the completed form. Once received, DWIHN will review and contact the necessary parties to complete the request for further evaluation.


Member Details

Phone


Referral Agency

Include City, State, Zip Code

Phone
Phone
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Submitter's Information