PNW Wound Specialist — Clinic & Facility Referral

PNW Wound Specialist — Clinic & Facility Referral

For clinics and facilities referring patients for mobile specialty wound care. Our PA-C or ARNP performs the initial evaluation and establishes the treatment plan. When home health is involved, we coordinate with their nursing team for conservative wound care. Otherwise, PNW RNs provide ongoing wound care under provider orders. A signed referral/order is requested before the initial visit. Phone: 509-209-9033 | Fax: 509-209-9032.
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Please submit your referral before leaving this page so your information is sent.
Referring Clinic/Facility
Clinic or Facility Name
Referring Contact Name

First NameLast Name
Contact Role
Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Clinic or Facility Fax
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email
example@example.com
Patient
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address Where Care Will Occur

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Residential Facility Name (if applicable)
Caregiver or Designated Contact Name

First NameLast Name
Relationship to Patient
Caregiver or Designated Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance
Primary Payer
Primary Member ID
Secondary Payer (if applicable)
Secondary Member ID (if applicable)
Upload Insurance Card or Face Sheet

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Wound Information and Supporting Records
Wound Location(s)

Other
Wound Diagnosis(es), if Known
Wound Duration
Specific Wound Location/Laterality
Current Wound Treatments and Orders
Reason for Referral
Supporting Records (recent progress notes, diagnoses, medications and allergies, current wound orders, relevant cultures/labs/vascular studies; PDF/JPG/PNG uploads accepted)

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Home Health
Is home health currently involved?
Home health agency name
Home health agency contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Infection Precautions
Known current or previous MDRO infection/colonization or other infection requiring precautions?
Organism or infection
Infection site
Dates of infection/colonization
Precautions required

Other
Referral Order
Order Method
I refer this patient to PNW Wound Specialist LLC for wound care evaluation and treatment.
Referring Provider Name

First NameLast Name
Signed Referral/Order

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Provider NPI
Order Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Provider Signature (electronic signing option only)
This form is not monitored continuously. Call 911 for a medical emergency.
Should be Empty:

PNW Wound Specialist — Clinic & Facility Referral

Referring Clinic/Facility

Patient

Insurance

Wound Information and Supporting Records

Home Health

Infection Precautions

Referral Order