Wyoming Partnership Access Line

MDT Referral Form

Please complete each of the fields below to request an MDT consultation (also known as a “Washington Evaluation”). If you have any questions about the referral form, please call 206-987-7932 or email us.

Seattle Children’s complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.