Referral Form for Providers

Download referral form for CCM Specialty Healthcare services. This form is intended for patients, caregivers, and healthcare providers to ensure accurate and timely Specialty care.

Instructions

Download the Form

Download the appropriate referral form for the patient.

Complete the Information

Fill in all required patient and guardian information accurately.

Submit the Form

Submit the completed form via fax, email, or in person as instructed.

CCM Specialty Healthcare – Form

Download the required neurology form. Please complete all applicable sections before submission.

CCM Specialty Pediatrics Referral Form

PDF • Required Form

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Web Referral Form

Please fill out this form to refer a patient to CCM Specialty Pediatrics Care. Ensure all required fields are completed. Our team will contact you within 1–2 business days.

CCM SPECIALTY PEDIATRICS REFERRAL FORM

1940 116th Ave NE, STE 200B ,Bellevue, WA 98004
Referral Direct Line: (425) 200-4387
Email: referral@ccmspecialtycare.com
General Inquiry: info@ccmspecialtycare.com
Tel: (425) 276-1825 | Fax: (855) 785-8770

1. Patient Information *

2. Referring Provider Information *

3.Select Pediatrics Referral *

Please Select..
  • ▶ Consult Referral
    • ▶ Cardiology
      • Heart murmur evaluation (New: 99203–99205 / Established: 99213–99215)
      • Congenital heart disease (New: 99203–99205 / Established: 99213–99215)
      • Syncope / fainting (New: 99203–99205 / Established: 99213–99215)
      • Chest pain (New: 99203–99205 / Established: 99213–99215)
      • Arrhythmia / palpitations (New: 99203–99205 / Established: 99213–99215)
      • Cardiomyopathy (New: 99203–99205 / Established: 99213–99215)
      • Kawasaki disease follow-up (New: 99203–99205 / Established: 99213–99215)
      • Pulmonary hypertension (New: 99203–99205 / Established: 99213–99215)
      • Hypertension (New: 99203–99205 / Established: 99213–99215)
      • Sports / activity clearance (New: 99203–99205 / Established: 99213–99215)
      • Prenatal cardiac consultation (New: 99203–99205 / Established: 99213–99215)
      • Others
    • ▶ Neurology
      • Seizure / epilepsy evaluation (New: 99203–99205 / Established: 99213–99215)
      • Developmental delay (New: 99203–99205 / Established: 99213–99215)
      • Headaches / migraines (New: 99203–99205 / Established: 99213–99215)
      • Abnormal movements / tics (New: 99203–99205 / Established: 99213–99215)
      • Cerebral palsy (New: 99203–99205 / Established: 99213–99215)
      • Neuromuscular disorder (New: 99203–99205 / Established: 99213–99215)
      • Regression (New: 99203–99205 / Established: 99213–99215)
      • Neurogenetic disorder (New: 99203–99205 / Established: 99213–99215)
      • Hypotonia / hypertonia (New: 99203–99205 / Established: 99213–99215)
      • Others
    • ▶ Allergy & Immunology
      • Food allergy (New: 99203–99205 / Established: 99213–99215)
      • Asthma (New: 99203–99205 / Established: 99213–99215)
      • Allergic rhinitis (New: 99203–99205 / Established: 99213–99215)
      • Eczema / atopic dermatitis (New: 99203–99205 / Established: 99213–99215)
      • Chronic urticaria / angioedema (New: 99203–99205 / Established: 99213–99215)
      • Recurrent infections (New: 99203–99205 / Established: 99213–99215)
      • Suspected immunodeficiency (New: 99203–99205 / Established: 99213–99215)
      • Eosinophilic disorders (New: 99203–99205 / Established: 99213–99215)
      • Others
    • ▶ Developmental & Behavioral
      • Global developmental delay (New: 99203–99205 / Established: 99213–99215)
      • Autism spectrum disorder evaluation (New: 99203–99205 / Established: 99213–99215)
      • ADHD evaluation (New: 99203–99205 / Established: 99213–99215)
      • Behavioral concerns (New: 99203–99205 / Established: 99213–99215)
      • Learning difficulties (New: 99203–99205 / Established: 99213–99215)
      • Emotional regulation issues (New: 99203–99205 / Established: 99213–99215)
      • Sleep problems (New: 99203–99205 / Established: 99213–99215)
      • Feeding behavior issues (New: 99203–99205 / Established: 99213–99215)
      • Others
    • ▶ Gastroenterology
      • GERD (New: 99203–99205 / Established: 99213–99215)
      • Chronic abdominal pain (New: 99203–99205 / Established: 99213–99215)
      • Constipation / encopresis (New: 99203–99205 / Established: 99213–99215)
      • Failure to thrive (New: 99203–99205 / Established: 99213–99215)
      • Inflammatory bowel disease (New: 99203–99205 / Established: 99213–99215)
      • Celiac disease (New: 99203–99205 / Established: 99213–99215)
      • Eosinophilic GI disease (New: 99203–99205 / Established: 99213–99215)
      • Chronic diarrhea (New: 99203–99205 / Established: 99213–99215)
      • Liver disease (New: 99203–99205 / Established: 99213–99215)
      • Others
  • ▶ Procedure / Test Referral
    • ▶ Cardiology
      • Echocardiogram (TTE) – 93306
      • Fetal echocardiogram – 76825
      • Electrocardiogram (ECG/EKG) – 93000
      • Holter monitor – 93224
      • Event monitor – 93268
      • Exercise stress test – 93015
      • Cardiopulmonary exercise test (CPET) – 93797
      • Ambulatory BP monitoring – 93784
      • Cardiac MRI – 75557
      • Cardiac CT – 75574
      • Transesophageal echocardiogram (TEE) – 93312
      • Cardiac catheterization – 93451
      • Electrophysiology study – 93619
      • Pacemaker / ICD evaluation – 93288
      • Others
    • ▶ Neurology
      • EEG – 95816
      • ▶ EMG / nerve conduction study – 95907 / 95886
        • Right Arm – 95909, 95860
        • Right Leg – 95908, 95860
        • Left Arm – 95909, 95860
        • Left Leg – 95908, 95860
        • Both Arms – 95911, 95861
        • Both Legs – 95810, 95861
        • Others
      • Prolonged EEG – 95812
      • Video EEG monitoring – 95951
      • Ambulatory EEG – 95812
      • Brain MRI – 70553
      • Spine MRI – 72158
      • Lumbar puncture – 62270
      • EMG / nerve conduction study – 95907 / 95886
      • Evoked potentials – 95925
      • Botox injections (spasticity) – 64612
      • Baclofen pump evaluation – 62360
      • VNS evaluation – 61885
      • Ketogenic diet program – 99214
      • Others
    • ▶ Allergy & Immunology
      • Skin prick testing – 95004
      • Intradermal testing – 95024
      • Patch testing – 95044
      • Serum IgE testing – 86003
      • Oral food challenge – 95076
      • Drug allergy challenge – 95076
      • Venom testing – 95115
      • Allergy immunotherapy (SCIT) – 95165
      • Sublingual immunotherapy – 95180
      • Biologic therapy administration – 96413 / 96372
      • IVIG / SCIG infusion – 96361 / 96365
      • Desensitization protocol – 95170
      • Others
    • ▶ Developmental & Behavioral
      • Comprehensive developmental assessment – 96110 / 96111
      • ADOS / ADI-R testing – 96112 / 96113
      • Cognitive / IQ testing – 96130 / 96131
      • Adaptive functioning assessment – 96116
      • Speech & language evaluation – 92523
      • Occupational therapy evaluation – 97165 / 97166
      • Physical therapy evaluation – 97161 / 97162
      • Medication management consultation – 99203–99205 / 99213–99215
      • School IEP / 504 support – 99213–99215
      • Others
    • ▶ Gastroenterology
      • Upper endoscopy (EGD) – 43235
      • Colonoscopy – 45378
      • Flexible sigmoidoscopy – 45330
      • Capsule endoscopy – 91110
      • pH probe study – 91034
      • pH impedance study – 91034
      • Breath testing (lactose, fructose, SIBO) – 91065
      • Anorectal manometry – 91122
      • Esophageal manometry – 91035
      • Abdominal ultrasound – 76700
      • MR enterography – 74283
      • FibroScan – 91200
      • Feeding tube management – 43752
      • Biologic infusion therapy – 96413 / 96365
      • Others

4. Diagnosis *

5. Special Instructions

6. Attachments

    Maximum total attachment size: 50 MB.