Purdy Medical Wigs – Patient Referral Form for Healthcare Professionals & Care Coordinators
Refer a patient for compassionate, coordinated medical hair-loss support.
This form is secure and designed to protect patient information.
Refer a Patient to Purdy Medical Wigs & DME Supplier This secure referral form allows healthcare providers to refer patients for medical wigs (cranial prosthesis), mastectomy products, and other DME services. Please complete the form below to streamline patient care and coordination.
Secure Referral Overview
This secure referral form is intended for physicians, oncology teams, nurses, social workers, care coordinators, case managers, health plans, and other authorized healthcare professionals referring patients for cranial prostheses and medically related hair-loss services.
1. Referring Professional Information
Full Name
*
Professional Title or Role
Organization / Practice / Health Plan
Department
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
Email Address
*
example@example.com
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
Please Select
Phone
Email
Text
Fax
NPI Number (if applicable)
How did you hear about Purdy Medical Wigs?
2. Patient Information
Patient Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
example@example.com
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Preferred Method of Contact
Please Select
Phone
Email
Text
Best Time to Contact
Please Select
Morning
Afternoon
Evening
Anytime
Permission to Leave Voicemail
Yes
No
3. Medical Hair-Loss Information
Diagnosis or Reason for Referral
*
Please Select
Chemotherapy
Alopecia
Post-mastectomy
Other
Is a prescription available?
Yes
No
Pending
Upload Prescription or Referral Documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
4. Cranial Prosthesis & Services Requested
Select Services Requested
Medical Wig (Cranial Prosthesis)
Mastectomy Products
Other DME Items
Other
Urgency of Referral
Routine
Urgent
ASAP
Patient Insurance Status
Insured
Uninsured
Unknown
Additional Notes
Internal Routing Field
5. Prescription & Medical Documentation
Insurance Company
Plan Name
Member ID
Group Number
Plan Type
Please Select
PPO
HMO
Medicaid
Medicare
VA
Other
Is a third-party administrator, care management company, or benefit administrator involved?
Yes
No
Company Name
Care Coordinator Name
First Name
Last Name
Care Coordinator Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
Care Coordinator Email
example@example.com
Front of Insurance Card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Back of Insurance Card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
What insurance assistance is being requested?
6. Insurance Information
Preferred fitting method
Please Select
In Person
Virtual
Mobile / In-Home
No Preference
Preferred Days
Preferred Time of Day
Morning
Afternoon
Evening
Does the patient have mobility or accommodation needs?
Yes
No
Additional fitting or accessibility notes
Urgency
Please Select
Routine
Within One Week
Urgent
Treatment Beginning Soon
7. Appointment & Fitting Needs
May Purdy Medical Wigs contact the patient directly?
*
Yes
No
Would you like Purdy Medical Wigs to provide referral status updates?
Yes
No
Preferred method for status updates
Please Select
Phone
Email
Text
Portal
Additional notes or instructions
Prescribing Provider Name
First Name
Last Name
Prescribing Provider Practice or Clinic
Prescribing Provider Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Prescribing Provider Email
example@example.com
Is a Letter of Medical Necessity available?
Yes
Pending
No
Upload Letter of Medical Necessity
Upload a File
Drag and drop files here
Choose a file
Cancel
of
8. Referral Confirmation & Authorization
I confirm that the patient has authorized this referral and/or that I am permitted to transmit the information provided for purposes of coordinating medically necessary services.
Confirmation
*
Yes, I Confirm
Referring Professional Name
*
First Name
Last Name
Electronic Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
9. What Happens Next
Step 1 – Referral Reviewed Step 2 – Patient Contacted Step 3 – Insurance Benefits Verified Step 4 – Prescription and Medical Documentation Reviewed Step 5 – Consultation and Fitting Coordinated Step 6 – Cranial Prosthesis and Insurance Process Completed as Applicable
SUBMIT PATIENT REFERRAL
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