PATIENT INFORMATION

First name

Last name

Birthday

Month

Day

Year

Address

Cell or Home phone number

Medicare Plan B Number:

Copy of Medicare Plan B card - Front

Copy of Medicare Plan B card - Back

Secondary Insurance (if applicable):

Secondary Insurance - Front

Secondary Insurance - Back

Policy Number:

Insurance Phone Number:

2. REFERRING PROVIDER

Name (Last, First, MI)

Specialty

Institution / Group Name

Provider ID

Provider ID (if required)

Address (Street, City, State, Zip)

Phone #

Facsimile/ Data #

3. REFERRAL INFORMATION

Type of Wound (e.g., diabetic ulcer, pressure ulcer, venous ulcer):

Reasons for Referral

Brief History, Diagnosis and Test Results

4. SERVICE DESIRED (PROVIDED CARE AS INDICATED)

Initial Consultation Only

Diagnosis Test (specify)

(specify)

Consultation With Specific Procedures

Other

(explain)

5. PLACE OF SERVICE

Mobile Service

Telehealth

Other

(explain)

Number of Visits (If blank, 3 visits are assumed)

Authorization # (If required)

Referral is Valid Until (Date) *(See carrier instructions)

Signature (individual completing this form)

Authorizing Signature (if required)

Referral certification is not a guarantee of payment. Payment of benefits is subject to a member’s eligibility on the date that the service is rendered and to any other contractual provisions of the plan/carrier.

Please attach any relevant medical records, wound care notes, and imaging reports to this referral form.

Submit this form via fax to:

(954) 237-8520

or email to: assistant@woundcarerus.com

For any questions, please contact WoundcareRus at

(954) 400-4644

File upload

Signature

Signature field is empty.

Date