WCMS Project Access referral form

WCMS Project Access® referral form

Instructions: Form is to be completed by the provider or an authorized staff member and submitted online. Project Access® will contact your office once the patient has completed the entire screening process and is enrolled. As the provider, you agree to see the patient free of charge.

To be enrolled, patients must meet all four of the following criteria:
- At or below 200% of Federal Poverty Level
- Between the age of 18 and 64
- Resident of Buncombe or Madison County for the last 6 months
- Uninsured- this includes Medicare Part A, Medicare Part B, Medicaid (Family Planning only is OK), Tricare, and any other insurance plan such as employee-sponsored or purchased on the ACA Marketplace.
We are unable to accept referrals for any injuries related to a motor vehicle accident or on-the-job accidents.

All required information is important for continuation of this program, so we can report accurate data to our grantors.
Date:*

MonthDayYear
Date
This patient is:*

New enrollmentAlready enrolled
Please select the appropriate box(es) below where you want to refer your patient.:*

Allergy/AsthmaCardiologyCardiovascular Surgery ConsultChiropracticCounseling ServicesDermatologyDiabetic EducationEndocrinologyENTGastroenterology-- Project AccessGastroenterology-- WNC-CRCSI (Age 45-75 w/ positive FIT)General Surgery ConsultGenetics/Personalized MedicineHematology/OncologyImaging (specify below)Infectious DiseaseInternal MedicineLab ServicesNephrologyNeurologyNeurosurgery ConsultObstetrics/GynecologyOphthalmology (Cataract surgery not offered)OptometryOrthopedicsPediatricsPhysiatryPrimary CarePhysical TherapyPsychiatryPulmonologyRadiation OncologyRheumatologySleep medicineSurgery (specify below)UrologyWound CareEndocrinologyOther
If you are requesting imaging, what type?

U/SCTMRIX-rayOther
Indicate surgery type
Enter medical referral reason for each requested specialty (ICD-10 OK, or type out. If requesting more than one specialty, please list individually and specify dx for that specialty)*
Preferred practice (PA staff will attempt to honor request. If no preference, type None. For a complete list of participating practices, please see the Project Access website
Patient information
Name*

1. First NameMiddle NameLast Name
Preferred Name
Date of birth*

MonthDayYear
Date
Race*
Latino/Hispanic?*

YesNo
4. Referring clinic patient ID#
This helps us when we have to communicate with your office.
5. Gender*

MaleFemaleOther
Preferred Pronouns
6. Interpreter Required?*

YesNo
If "yes", what language?
7. Does the patient require any additional accommodations?*
8. Is the patient diabetic?*

YesNo
If "yes", enter most recent HbA1c Value
Date of Last HbA1c (enter 11/11/1111 if not applicable)*
10. How should we send the application to the patient?*

EmailMail
11. Primary Phone*
Alternate Phone
12. Email Address (if no email address, type none@noemail.com)*
We will email an application to the patient. Please verify that patient agrees with this.
13. Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
14. Home address (write "same" if home and mailing address is the same)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider information
1. Electronically sign below OR upload provider's signed orders here. If this form is electronically signed, please do NOT attach chart notes or lab orders. We only require a signature and this submitted form.

Cancelof
2a. Provider Name*
2b. Provider signature (Note: by e-signing here you attest that you are either the ordering provider or have been authorized to complete this referral on their behalf):
Provider signature

Clear
3. Provider type*

MDDOPANP
4. Practice name*
5. Phone*
6. Extension
7. Office Contact Name*
8. Fax*
We will inform you of this referral's status via fax
Has patient been given application in-clinic?

YesNo
Notes: any other pertinent information. If the patient is under 18, please include a parent or guardian's name.
Should be Empty:

Patient information

Provider information