Request Home Visit Order

Serving NY & NJ

Advanced Mobile Wound Care

Prevent Hosptal Admissions and Readmissions With Effective and Advanced In-Home Treatments

New patients must be registered, the only way to register a patient is by Submitting a Case below or by faxing order/clinicals to:

FAX - 718 - 475 - 3676

PHONE - 516 - 289 - 3955

Medicare Plans Accepted

1 - 3 Days From Referral to Visit

General Questions?📧 Email Us
- 1. Is this request for at-home woundcare for you or someone else?*
  
  For meFor someone else
- Referring Organization/Facility/Physician *
- What is your relationship to the patient?*
- What is your name?*
- Referring Person or Organization Best Phone Number*
  Format: (000) 000-0000.
- What is your email*
- 2. Are you referring this patient on behalf of a Home Health Agency, Visiting Nurse Service, senior living facility, telehealth agency or a medical group, physician or organization?*
  
  YesNo
- Patient Full Name*
  
  Last NameFirst Name
- Patient Date of Birth*
  
  MonthDayYear
- Patient Phone Number*
  What is the best phone number to schedule care?Format: (000) 000-0000.
- Wound Details
  
  Share the key wound information and current concerns.
- 1. What type of wound(s) is the patient dealing with?*
  
  Slow or non-healing woundPressure sore / bed soreSurgical or post-operative woundBurnInjuryOther / Not Sure
- 2. How long has the patient had this/these wound(s)?*
  
  Less than 2 weeks2–6 weeksOver 6 weeksIt’s been on and off for a whileNot sure
- 3. Please describe the issue *
  The more details the better.
- 4. Is/are the wound(s) chronic/stubborn or not healing quickly with standard care?*
  
  YesNoNot sure
- 5. Is/are the wound(s) worsening?*
  
  Yes, it’s getting worseNo, it’s stableNot sure
- Location & Living Situation
  
  Tell us where the patient lives and any support available.
- 6. Does patient have a caregiver, aide or home health attendant?*
  
  YesNoNot sure
- Caregiver, Attendant Phone Number (If available)
  Please enter a valid phone number.Format: (000) 000-0000.
- 7. Does patient reside in a facility/senior living community?*
  
  No, patient resides in a private home.Yes
- 8. Name of Facility/Community
- 9. Patient Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- 10. Optional: Apartment/Room Number
- Medical & Insurance
  
  Add relevant medical history and coverage details.
- 11. Please list any medical conditions the patient has or you are aware of (e.g., diabetes, high blood pressure, asthma). If none or unknown please type: No known medical conditions.*
- 12. Primary Insurance Provider *
  To verify coverage please enter the patient’s Medicare number. All Medicare recipients have a government-issued 11-character Medicare ID.
- 12a. Primary Policy Number*
  .
- 13. Secondary Insurance Provider
  Leave blank if no other or secondary insurance.
- 13a. Secondary Policy Number
  Leave blank if no other or secondary insurance.
- Uploads
  
  Attach any helpful documents or photos, if available.
- Optional: Attach/Use Camera images of wound(s), If available, recommended.
  
  Please ensure photos are well-lit and in focus. You can upload mutliple images.
  Cancelof
- Optional: Patient face sheet,(demographics) prescription etc.
  
  Cancelof
- Optional: Comments
- Consent
  
  Review and confirm authorization before submitting.
- I confirm this information is accurate and I’m authorized to submit it, and by submitting I agree to the Authorization & Consent, Privacy Policy, and Terms, and consent to be contacted by phone, text, or email for care coordination, including contacting others whose information is provided.*
  
  Yes I agree with the above statement.
- 🌟 What Care Professionals Are Saying About Specialty Wounds:
  
  “I’ve ran a home health agency for over 10 years, and I’ve never worked with a wound care team this responsive. I send in the referral, and my patient is seen within a day. The staff are kind, professional, and always explain the plan so I can help between visits. It makes my patients — and me — feel supported.”
  
  Denise R., HHA, Brooklyn, NY
  
  “Partnering with Specialty has improved our wound healing outcomes tremendously. The communication is excellent — Our readmissions are down significantly."
  
  Maria L., Nursing Home Discharge Planner, Long Island, NY
  
  "As a housecall doctor, I depend on reliable wound care specialists who understand the urgency of treating chronic wounds. Specialty Wounds has become my go-to partner. They see patients quickly, provide thorough assessments, and their follow-up reports are top-notch. They’ve become an essential part of my practice.”
  
  Dr. David K., Housecall Physician, Northern NJ
  
  “Before we started using SpecialtyWounds.com, scheduling wound care visits was a constant headache. Now our patients get seen within 24 hours — sometimes the same day — The families notice the difference, and our rehospitalizations are down.”
  
  Karen P., Assisted Living Wellness Director, Bronx, NY
Should be Empty:

Wound Details

Location & Living Situation

Medical & Insurance

Uploads

Consent