PCA Provider Form for Patient Matching
Welcome, valued PCA provider! Your information here helps our system accurately match your practice with incoming patient referrals.
Practice Name
*
Head Provider Name
*
Dr, NP, MD, PD, DO, PA, etc.
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Primary Email
*
This is where we will send Patient Referrals (Must be HIPAA Compliant)
Practice Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your service area? Please list counties or zip codes
*
ex) Los Angeles county, Ventura county, Monterey county, San Bernadino county, Santa Barbara county,... or 90001, 90005 90009, 90013, 90016,....
How many providers are within your group? What licensures?
*
ex) 1 MD, 3 NPs. 2 LPNs ...
What are your providers' primary specializations relevant to wound care?
*
ex) Pressure Ulcers, Surgical Wounds, Podiatry, Vascular Surgery, Dermatology, ...
What types of insurance do your providers accept?
*
ex) Medi-Cal, Medicaid, Blue Cross, Aetna, ...
How soon can you schedule an initial visit?
*
ex) Within the same work day as receiving the referral
How soon after seeing a patient will visit notes be available?
*
ex) Within 24 hours
Any additional notes or information about your practice?
*
ex) We only service San Bernadino on Tuesdays and Thursdays
My team will have visit notes ready within:
*
ex) Within 24 hours of visiting the patient
My team will visit the patient within:
*
ex) Within the same work day as receiving the referral
I verify that the information provided is accurate and I will adhere to the time standards that I have provided.
*
Continue
Continue
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