HealWell of Texas Referral Form
Last Name
Patient Name
First Name
Date of Birth
Social Security Number
Patient Phone Number
Format: (000) 000-0000.
Type of Insurance
Reason for Referral
Evaluate/Treat
Procedures Only
Other
Referring Facility Name
Facility Fax Number
What type of wound does the Patient have?
Where on the body is the wound located?
Please describe where the wound is located arm, head, leg, hand, foot, chest, back etc
Is there any existing imagine for the condition?
Yes
No
Referral Diagnosis Description / Code
Please submit the following documents with referral
Most recent Bloodwork (if applicable)
Current Med List and Active Problem List▢Last 4 Office Visits with referral indications, brief
Assessment referral orders documented in note
Most recent Bloodwork (if applicable)
Demographic Sheet
MRI Report included
X-Ray Report included
Copy of Photo ID
Copy of Insurance Card
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Fax to: 8
88-777-8306
Thank You for the Referral.
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