Hearing Loss

Diagnosis Hearing Loss
Department Child Development and Rehabilitation Center; Otolaryngology and Head and Neck Surgery

1. Start the referral process:

For referrals to Child Development and Rehabilitation Center, use your own referral form or notes* or download our form:



CDRC new patient referral form

For referrals to Otolaryngology and Head and Neck Surgery, use your own referral form or notes* or download one of our forms:

2. Gather records:

For pediatric referrals, Child Development and Rehabilitation Center:

  • Any chart notes and imaging related to referral

For adult referrals, Otolaryngology and Head and Neck Surgery:

  • If hearing loss is not otherwise specified:
    • Clinic audiogram
    • Any recent hearing tests
    • Any chart notes related to hearing loss
    • Any recent CT/MRI of head

For pediatric referrals, Otolaryngology and Head and Neck Surgery:

  • If child is older than 6 months old:
    • Any chart notes and imaging related to referral
    • If child is less than 6 months old:
    • Any chart notes, imaging and hearing tests related to referral/reason for visit.

       
  • If child is less than 6 months old:
    • Any chart notes, imaging and hearing tests related to referral/reason for visit.

3. Fax the referral and all records to 503-346-6854.

* Referral notes or forms should include:

  • Patient name, date of birth, sex, address and phone number
  • Referring provider’s name, address and phone number
  • Diagnosis or reason for referral
  • Department patient is being referred to
  • Most recent chart notes supporting the diagnosis or reason for referral

For help or to arrange provider-to-provider advice, call 503-494-4567.

Date Revised May 01, 2024