Clinical Referral and Evaluation Request

Clinical Referral & Evaluation Request
For a wound care referral via fax we typically need:

• Patient face sheet (demographics + insurance)
• Most recent H&P or provider note
• Current medication list
• Wound history and duration
• Most recent wound measurements
• Any recent labs or vascular studies (if available)
• Home health orders (if already established)
• Primary care provider information

If your team already has photos, those are helpful but not required for referral.

You can fax everything to 509-209-9032, and we will review it within 24 hours. If the patient is appropriate, we will coordinate directly with your RN and the ordering provider to ensure plan-of-care alignment.
- Referring Provider Name*
- NPI*
- Practice Name*
- Phone *
  Format: (000) 000-0000.
- Fax*
  Format: (000) 000-0000.
- Email*
- Is this an Evaluation & Treatment request?
  
  YesNo
- Is advanced therapy being requested?
  
  YesNo
- Full Legal Name*
- DOB*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Service Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Facility Name (if applicable)
- Insurance Type*
- Insurance ID
  
  Cancelof
- Secondary Insurance?
  
  YesNo
- Insurance
- Insurance ID
  
  Cancelof
- Wound Location (anatomical site)*
- Wound Type*
- Approximate Date of Onset*
  
  MonthDayYear
  Date
- Current Size (Length / Width / Depth)*
  
  (cm)(mm)
- Length(mm)* Width(mm)* Depth(mm)*
- Length(cm)* Width(cm)* Depth(cm)*
- Is bone/tendon/muscle exposed?*
  
  YesNo
- Signs of infection?*
  
  YesNo
- Drainage level*
- Pain present?*
  
  YesNo
- Has wound worsened or stalled?*
  
  YesNo
- Checkbox grid:*
  
  Debridement performedOffloading used (DFU)Compression used (VLU)Moisture balance maintainedInfection treatedNutritional factors addressedUnknownOther
- How many weeks of conservative care have been attempted?*
- PNW Wound Specialist begins with conservative management in accordance with Medicare medical necessity standards. Advanced therapy may require documented conservative trial.”
- Please describe why skilled wound care is medically necessary at this time.*
- *
  
  Diabetes?PAD / vascular disease?Immobility?History of non-healing wounds?Concern for malignancy?ABI available? (Upload option)Recent A1C? (Upload option)
- ABI Upload
  
  Cancelof
- A1C Upload
  
  Cancelof
- ⚠️ Required upload OR check box
  
  Documentation will be provided via Fax to PNW Wound Specialist @ 509-209-9032 in order to process referallI will upload
- Most Recent Progress note
  
  Cancelof
- Most recent wound photos
  
  Cancelof
- Vascular studies (if applicable)
  
  Cancelof
- Labs (if applicable)
  
  Cancelof
- Advanced Therapy Request – Additional Information Required
- What advanced therapy is being requested?*
  
  Skin substituteNPWTOther
- How many prior applications have been performed?*
- Has wound improved in last 4 weeks?*
  
  YesNo
- Current surface area*
- Why is conservative care insufficient?*
- Has biopsy been considered if wound enlarging?*
  
  YesNo
- Is supervising physician aware?*
  
  YesNo
- Order & Authorization
- Evaluation & Treatment Order
- Frequency requested
- Duration requested
- Provider Signature (e-sign)*
- Date
  
  MonthDayYear
  Date
- Submission of this referral does not guarantee coverage. All services are subject to Medicare medical necessity standards and supervisory review when required.
Should be Empty:

Clinical Referral & Evaluation Request

Advanced Therapy Request – Additional Information Required

Order & Authorization