Patient Referal Form

Patient Referal Form

Please allow at least 1 business day for an update. For further assistance please contact intake@patientcare-advocates.com
Patients Name*

First NameLast Name
Where should we send our provider for the appointments? *

Street Address

Street Address Line 2

CityState

County & Zip Code (ex: Kern County, 93303)
What type of residence is this?*
Who should our provider call to schedule the appointments? What is the best phone number?*
E.g. Please call patients niece at 222-333-5555 and ask for Paula to schedule.
Patients Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patients Email
example@example.com
Patient Birth Date

MonthDayYear
Ex) 11/15/1959
What is the insurance type? Please also include insurance number.*
Please include insurance number and insurance type. If Medicare, please specify if if Part A, Part B etc.
Wound Photo(s)

Wound photos will help us know which provider will best fit this patients needs. Keep in mind: MANY PROVIDERS REQUIRE THIS
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H&P, Demographics, Face Sheet

Keep in mind: MANY PROVIDERS REQUIRE THIS
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Additional Patient Info

Anything else that would be helpful for this referal. E.g. Doctors order, wound info, progress notes, insurance card photo, etc. Keep in mind: MANY PROVIDERS REQUIRE THIS
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What can you tell us about the wound?*
What type of wound is it? What is the size of the wound? Where is the wound located? Etc. DO NOT PUT N/A, this question is required in order for us to send a provider that best fits patients needs.
PLEASE NOTE THAT MANY PROVIDERS WILL REQUIRE FACESHEET, H&P, WOUND PHOTOS, INSURANCE CARDS, ETC.

if you choose not to submit these files, keep in mind that it will delay your referal process.
Who is referring the patient? *

First NameLast Name
Referral Agent Code
Code for your Referal Agent e.g. JAMES2232
Referred by email
Email address of the person referring this patient
Referred by phone number
Phone # for the person referring this patient
Who else does our provider need to communicate with?
If you have answered the above question, please provide the best phone number to contact this person at.
If you have asked the specialist to communicate with a Hospice, Home Health, etc., please provide their number hereFormat: (000) 000-0000.
Caretaker phone number
If applicable, Please enter a valid phone number.Format: (000) 000-0000.
Caretaker Email
If applicable, example@example.com (Must be HIPPA Compliant)
Yes, I have spoken to both parties and discussed that this patient will be referred to Patient Care Advocates to be connected to a provider on the Patient Care Advocate network.No, I have not spoken with the necessary parties
Notes & Additional Information*
Please include as much information as possible to ensure a smooth and efficient referral process. Note any special request, and if the patient needs to see a specific specialist, please specify.
Should be Empty: