Hyperbaric Oxygen Therapy & Wound Care Referral
HIPAA COMPLIANT FORM
Patient Name
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First Name
Last Name
Patient Date of Birth
Patient Phone Number
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Insurance Provider
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Aetna
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Blue Cross Blue Shield
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Cigna
HAP
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Policy Number
Referring Physician/Clinic Name
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Phone Number
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Referral is for:
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Hyperbaric Oxygen therapy
Wound care
Both HBOT and Wound care
Other
Indication for Hyperbaric Oxygen Therapy Referral
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Acute Crush Injury
Acute Thermal Burns
Acute Traumatic Ischemia
Actinomycosis
Chronic Refractory Osteomyelitis
Compromised Skin Grafts or Flaps
Diabetic Foot Ulcer
Gas Gangrene (Clostridial Myonecrosis)
Hemorrhagic Cystitis
Idiopathic Sudden Sensorineural Hearing Loss
Necrotizing Soft Tissue Infections
Osteoradionecrosis (ORN) of the Jaw
Other (Please Specify Below)
Radiation Proctitis
Radiation Soft Tissue Damage
Wound Care
Other (if applicable)
Would you like the Revitalize Me team to manage wound care for this patient?
Yes
No
Indication for Wound Care Referral
Other information, referral requests, Wound description, how Long has wound been present, etc. or notes:
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