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IHA What to send

Clinic Name	What to Send to M-CALL	Location Options
ADD	If patient is already diagnosed with ADD, the referral will be handled by Psychiatry or Behavioral Medicine. If the patient if not diagnosed yet (i.e., "evalute for ADD," "rule out ADD"), the referral may go to Psychiatry or Neuropsychology, depending on PCP preference.	N/A
Adolescent Medicine	M-CALL Form	Briar Bldg. 5
Adrenal Tumor Clinic	M-CALL Form	Cancer Ctr level B1 Reception C
Audiology: Pediatric	M-CALL Form NOTE: If the child has special needs, the clinic will need to schedule more time. Please indicate if the child requires any special care due to a diagnosis of: ADD, ADHD, Down's Syndrome	Taubman Ctr Briarwood Brighton Livonia
Back and Pain Center	M-CALL form along with medical docuementation	Brighton Burlington Canton Chelsea
Behavioral Medicine	M-CALL Form Patients 4 yrs. and younger go to Behavioral Medicine; 5 yrs. and up go to Pediatric Psychiatry.	Taubman Ctr Ypsilanti H.C.
Bone Density Scan	M-CALL Form & signed radiology req Clinic schedules between 9-1 daily.	East Ann Arbor
Bone Scan	M-CALL Form & nuclear medicine req.	UH
Breast Care Center	M-CALL Form and medical documentation	Cancer Ctr level B1 Reception C
Cardiology: Testing	M-CALL Form along with signed diagnostic service requisition	various
Cardiology: Urgent or Dr. Eagle	M-CALL form along with all testing records (EKG, ECHO)	Taubman Ctr Level 3 Reception B
Cardiology: Non -Urgent	M-CALL Form along with all cardiology testing.	Taubman Ctr Level 3 Reception B
Child Protection Team	M-CALL Form
Coagulation Clinic	M-CALL Form All medical documentation regarding issue/diagnosis	Cancer Ctr level B1 Reception B
Cognitive /Movement Disorders Cognitive Disorders: 50 yrs. + Movement Disorders: 18 yrs. +	M-CALL Form NOTE: They will set up 3 appts.: 1) Initial evaluation with physician 2) Neuropsych testing (takes 3-4 hrs.) 3) Appt. with physician to go over test results	East Ann Arbor
Concussion Clinic	M-CALL Form & medical documentation	Adults: Briarwood #4 Peds: Burlington
Dermatology	M-CALL Form We must have the following information to schedule: If pcp personally examined pt, clear diagnosis or issue, what medications have already been tried. NOTE: Wart removal no longer seen in Derm. Please refer patient to Plastic Surgery.	Taubman Ctr Dominos Dexter
Diabetic Education	M-CALL Form stating Diabetic Education and which type of diabetes the patient has.	Dominos Farms
Diabetic Counseling	M-CALL Form stating Diabetic Counseling and which type of diabetes the patient has.	Dominos Farms
Direct Access Clinic (Colonoscopy, EGD and Flex Sig scheduling)	M-CALL Form We need the answer to these 7 questions: 1. Can the patient sign his/her own consent? 2. Does the patient weigh more than 350lbs? 3. Does the patient have an ICD (intra-cardiac devise)? 4. Is the patient diabetic? 5. What kind of prep does PCP want patient to use? 6. Does the patient live in a group home? 7. If a pulmonary patient, have they tested positive for TB?	Univ. Hosp. East Ann Arbor Health Center
Doppler Vascular Lab	M-CALL form & signed diagnostic service req We need the answer to these 2 questions: 1. Is the patient diabetic? 2. What is the patient's weight?	CVC
Dysphagia Team, Ped Swallow Study	M-CALL Form NOTE: M-CALL FORM MUST BE SIGNED BY PCP AND MADE OUT TO: OT/SLP.	Mott Lev 2
EEG EMG	M-CALL & signed diagnostic service req	A: Taubman Center P: Mott
EKG	Adult EKGs are available M-F 8:30 - 4:30 on Walk-In basis.Peds EKGs are available M-F 8-5 on walk in basis. Clinics advise calling ahead to avoid long wait times & to ensure pt. has correct documents. Must hand carry signed script to appt.	A: Taubman Center P: Mott
Encopresis Clinic	M-CALL Form & physician notes NOTE: Can also be seen in Pediatric Behavioral Medicine or Pediatric Psychiatry.	Taubman Center
Endocrinology, Ped	M-CALL form & Growth chart, notes from last doctor visit, and any labs required to schedule.	Taubman Center
Event Monitors, 30-day	M-CALL form & signed diagnostic req NOTE: Monitor will be sent to patient, M-CALL will not be notified of an appointment date	N/A
Event Monitors, 24 hr. (Holter)	M-Call Form & signed diagnostic req NOTE: Monitor will be sent to patient, M-CALL will not be notified of an appointment date	N/A
Gastroenterology, Adult	M-CALL form & medical documentation	Taubman Center
Gastroenterology, Liver Clinic	M-CALL Form and medical documentation	Taubman Center
Gastroenterology, Ped	M-CALL Form & Growth chart, notes from last doctor visit, and any labs required to schedule	Taubman Center Canton
Genetics, Adult	M-CALL and medical documentation	Taubman Center
Genetics, Ped	M-CALL form and medical documentation including summary of issue, notes from pcp, tests, labs Clinic will not schedule without this information.	Taubman Center
Gynecology Oncology	M-CALL Form and a confirmed diagnosis of cancer. "Rule out cancer" referrals go to Gynecology	Cancer Center
Headache Clinic (Dr. Cooper through AN-Back & Pain)	M-CALL Form & medical documentation.	Burlington
Helmet Clinic (Plagiocephaly)	M-CALL Form& signed script	S. Industrial
Hematology/Oncology	M-CALL Form & medical documentation	Cancer Center
Infection Disease Pediatric	M-CALL Form & medical documentation	Taubman Center
Internal Medicine: Allergy, Cardiology, Endocrinology,Gastroenterology, Geriatrics, Hypertention, Infectious Disease, Nephrology, Pulmonary, Rheumatology,	M-Call Form & medical documentation For cardiology tests please see "Cardiology-non-urgent".	Locations depend on what specialty patient is seeing.
Lipid Clinic	M-CALL and medical documentation	Dom Farms
Lipid Dietician	M-CALL Form and medical documentation	Dom Farms
Liver Clinic	M-CALL Form and medical documentation	Taubman Center
Mammography	M-CALL Form Requires signed requisition. NOTE: Patients needs to hand-carry films (if non-UM) and provide date of last mammogram.	Cancer Center Briarwood Brighton Canton East Ann Arbor
Clinic Name	What to Fax	Location Options
MPower (13-17 yrs) Pediatric Weight Management Program MPower Junior is for patients 8-12 yrs w/ BMI at or above the 95th percentile.	M-CALL Form & medical documentation	Burlington Building
Maxillofacial Surgery	M-CALL form, clear diagnosis, and medical documentation	UH B1
Medical Procedure Unit - Direct Access (colonoscopy, EGD, flex sigmoidoscopy scheduling)	M-CALL Form We need the answer to these 7 questions: 1. Can the patient sign his/her own consent? 2. Does the patient weigh more than 350lbs? 3. Does the patient have an ICD (intra-cardiac devise)? 4. Is the patient diabetic? 5. What kind of prep does PCP want patient to use? 6. Does the patient live in a group home? 7. If a pulmonary patient, have they tested positive for TB?	Univ. Hosp. East Ann Arbor Health Center
Melanoma	Must have proven Melanoma diagnosis. M-CALL form & medical documentation.	Cancer Center
Michigan Sinus Center	M-CALL Form Requires sinus CT beforehand, or to be done at clinic.	Livonia Specialty Care Center
Neonatology Follow-Up Clinic	M-CALL Form	Taubman Center
Nephrology, Ped	M-CALL form and medical documentation	Taubman Center
Neurology, Ped	M-CALL form along with office notes related to diagnosis, diagnostic reports, lab results, growth curves(if relevent), School related diagnosis: need copies of school district reports.	Taubman Center
Neuromuscular Clinic, Peds Neuromuscular Clinic, Adult	M-CALL Form & Medical documentation M-CALL Form & Medical documentation	Burlington Bldg Taubman Center
Neuropsychology	M-CALL Form and medical documentation including notes from last physician visit. NOTE: parents will need to hand carry all testing information to appointment	Commonwealth
Neuropsychology through PM&R (brain stem injuries)	M-CALL Form and medical documentation including notes from last physician visit.	Burlington
Neurosurgery, Adult	MUST HAVE A CURRENT (W/IN 6 MONTHS) MRI. Fax M-CALL form to schedule along with medical documentation.	Taubman Center
Neurosurgery, Ped	M-CALL Form & medical documentation	Taubman Center
Nutritional Services	M-CALL Form NOTE: For increased/decreased lipids, see "Lipid Dietician."	Taubman Center East Ann Arbor Canton Brighton
OB/GYN	M-CALL Form	Taubman Center Briarwood Brighton Canton Livonia Specialty Ctr East Ann Arbor
Occupational Therapy, Adult	M-CALL form signed by PCP, or signed script.	Briarwood MedRehab
Occupational Therapy, Ped	M-CALL form signed by PCP, or signed script.	Mott Hosp
Ophthalmology	M-CALL Form	Ann Arbor Brighton Canton Livonia Specialty Ctr Milford Ypsilanti Briarwood
Oral Surgery	M-CALL Form	University Hospital
Orthopaedic Surgery, Foot	M-CALL Form along with all diagnostic testing results (MRI/X-Ray Reports). Some foot and ankle issues can be seen in PM&R. M-CALL representative will schedule appropriately to ensure that patient is seen as soon as possible.	South Main Orthopaedics
Orthopaedic Surgery, Hand	M-CALL Form and medical documentation. NOTE: Very important to indicate if any tests have been done & to fax documentation	South Main Orthopaedics
Orthopaedic Surgery, Hip/Knee/Shoulder	M-CALL Form & if injury is sports related & location of injury NOTE: Very important to indicate if any tests have been done & to fax documentation	Taubman Center Dominos Farms Brighton Canton
Orthopaedic Surgery, Pelvis/Trauma/Femur or Hip fracture	M-CALL form & medical documentation NOTE: Very important to indicate if any tests have been done & to fax documentation	Taubman Center
Orthopaedic Surgery, Spine	M-CALL form & medical documentation	Taubman Center
Orthotics/Prosthetics	M-CALL form and signed script.	2850 S. Industrial
Otolaryngology/Oncology: Head & Neck lumps, bumps and masses	M-CALL form & medical documentation. All lumps/bumps/masses on head & neck are seen in OTO-ONC. If mass is 1cm or greater, patient must first have either a fine needle biopsy or CT with contrast.	University Hospital
Otolaryngology	M-CALL form NOTE: Some appts will require patient to get a hearing test Sinus appts: Pt will need a recent sinus CT prior to seeing physician	Taubman Center Brighton (hearing test only) Livonia Specialty Care Ctr Michigan Sinus Center
Pain Clinic	M-CALL form & extensive medical documentation.	Burlington Brighton Canton
Physical Therapy, Adult	Signed M-CALL form or signed script. Must indicate which limb needs physical therapy. Please note which location patient prefers.	Univ Hosp Brighton Canton Domino's Farms Ice Cube (Ann Arbor) Livonia Health Ctr Briarwood Spine Clinic NOTE: Not all locations see all issues
Physical Therapy: Lymphoedema	M-CALL form: must be signed or have a signed script. NOTE: Therapy includes: manual massage, wrapping, exercise, skin and self care.	Univ Hosp.
Physical Therapy, Peds	M-CALL form: must be signed or have a script.	Mott
PMR, Adult or Peds	M-CALL form	E. Eisenhower STE 100
Podiatry	M-CALL Form Will see routine foot care and problems associated with diabetic foot	Dominos Farms
Psychiatry	M-CALL Form will be faxed to clinic for scheduling but we will not be notified of an appoitntment. NOTE: Requires patient (or parent) to contact their insurance provider (contact number on back of insurance card.)	Upjohn Building
Psychology, Ped	M-CALL Form will be faxed to clinic for scheduling but we will not be notified of an appoitntment. NOTE: Parent may get a faster appointment if they call directly.	Taubman Center
Clinic Name	What to Fax	Location Options
Pulmonary, Ped	M-CALL form along with medical documentation, labs, growth chart	Taubman Center
Pulmonary Function Lab Pulmonary Function Lab/Methacholine Challenge test	M-CALL form & signed diagnostic service req M-CALL form & signed diagnostic service req & meth. challenge patient prep form.	Taubman Center Taubman Center
Radiology	M-CALL Form along with SIGNED requisition	Locations Dependent on type of test. Most tests done at Univ. Hosp.
Rehabilitation Psychology /Neuropsychology	M-CALL Form along with Neuropsychology form and medical documentation required	A: MedRehab P: Mott
Rheumatology, Adult (age 17 and up)	M-CALL Form & medical documentation	Taubman Center Briarwood
Rheumatology, Adult (older than 60 yrs)	M-CALL Form & medical documentation	East Ann Arbor
Rheumatology, Ped (age 16 and less)	M-CALL form along with medical documentation	Taubman Center
Semen Anaylsis	No referral required. Patient is to call ART lab and make own appointment and take rx with him. Phone: 734-763-5384	Mott Expansion, Level 4
Sleep Clinic	M-CALL Form & medical documentation NOTE: Patients must first be seen in the Neurology Clinic before seeing a sleep physician.	Adult: Taubman Center Ped: Taubman Center
Smoking Cessation Clinic	M-CALL form NOTE: Patient is responsible for following up with clinic.	North Ingalls Bldg
Speech Therapy, Adult	M-CALL form: must be signed or have a script.	Univ Hosp
Speech Therapy, Ped	M-CALL form: must be signed or have a script.	Mott
Spine Clinic: Physician Appt.	M-CALL form	Burlington Bldg., 325 E. Eisenhower
Spine Clinic: PT	M-CALL form: must be signed or have a script.	Burlington Bldg., 325 E. Eisenhower Brighton Health Center
Thoracic Surgery	M-CALL Form & medical documentation	Taubman Center
Thyroid Scan	M-CALL form. NOTE: this is a 2-day test. Only open Tues and Thursdays. This is a 1-day test if PCP gives patient a rx for iodine tablet.	Univ. Hosp
Travel Clinic	M-CALL form NOTE: Need to know where patient is going (country/region) and specific travel dates.	Taubman Center
Urology	M-CALL Form & medical documentation	Adult: Taubman Center Level 2 Peds: Taubman Center Level 1 Peds:Livonia Health Center
Vascular Lab/Doppler	M-CALL form & signed diagnostic service req	CVC
Vascular Surgery	M-CALL form. NOTE: This is for a physician visit without a diagnosis of varicose veins.	Taubman Center
Vascular Surgery-Varicose Veins or Vein Center	M-CALL Form NOTE: All variocse veins are seen in Livonia at the Vein Center.	Livonia Specialty Care Center
Vasectomy	M-CALL form NOTE: Can be scheduled in 2 locations. Depending on the location, we will be scheduling just the consultation OR the consultation and the procedure.	Taubman Center Livonia Specialty Care Center
Vertigo Clinic	Fax M-Call referral to schedule; they will make up to 4 appointments: 1) Vestibular Therapy- 1 hr. evaluation by physical therapist (Positional vertigo only) 2) Audiology test 3) Vestibular testing- 2-3 hr. test for balance 4) Otolaryngology physician appt.- For final evaluation and test results NOTE: There is a possibility that clinic will want PT ordered, in that case the clinic will call M-CALL to request a signed req or script. M-CALL will contact PCP.	Med Inn

Weight Management

MPower (13-17 yrs)
PediatricWeightManagement Program

MPower Junior

is for patients 8-12 yrs w/ BMI at or
above the 95th percentile.

M-CALL Form & medical documentation

Burlington Building

Wound Care Clinic (plastic surgery)

M-CALL form & medical documentation

Dominos Farms

University of Michigan Health System, 1500 E. Medical Center Drive Ann Arbor, MI 48109 734-936-4000
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