Children's Special Health Services
Pediatric Specialty Clinic Referral Services
Pediatric Specialty Clinics are sponsored by Children's Special Health Services of the Montana Department of Public Health and Human Services and supported by the health facilities in the community where clinics are held. Insurances, Medicaid and CSHS cover the cost of services; no child or youth is turned away.
If you would like to refer a child or youth to any of the Pediatric Specialty Clinics, please read the following information and fill out the PDF form below. If this form is not working for you, please submit an e-mail message to CSHS.
Make a referral to Pediatric Specialty Clinic:
- Download the PDF form.
- Enter all information requested on the form.
- Upon completion, the form must be printed out in order to "save" what you have entered. If you close the PDF form and don't print out what you have entered, your information will be lost. The information entered into the PDF form cannot be saved.
- Fill in any additional information by hand, if necessary.
- Mail or fax the completed form to CSHS.
You can also make a clinic referral by using the following:
- Download the PDF form, print it out, fill it in by hand, mail or fax it to CSHS.
- Call CSHS.
- Contact one of the Regional Clinic Contacts.
When filling out the form on your computer, you can use the following tools:
- Click on a field with your mouse to select the field. A cursor will appear and you can type in your information.
- The Tab key will move you forward from field to field. Shift + Tab key will move you backwards from field to field.
- Delete an entry by highlighting the information and pressing delete, backspace, or just type over the highlighted information.
- Check boxes can be checked by clicking on the box with your mouse or by selecting the box and pressing the Enter key or space bar. (Hitting the Enter key or space bar again will remove the checkmark.)
- Standard Windows-based commands will work in the PDF file. Control + C will copy, Control + V will paste and Control + X will cut.
The following tools only work when the cursor is not in a field:
- Arrow keys right and left move page to page through the document. Arrow keys up and down scroll through the document.
- The Enter key will move you through the document a half-page at a time.