New Patient Referral (SNF)

New Patient Referral Form:

Thank you for your referral, if you need any assistance filing out this form, please contact us at 855-255-1750 and choose option 2.
PLEASE NOTE: Completed form must be received 72 hours prior to Wound Rounds to ensure patient registration and insurance authorization occurs.

*Please contact us if you would like to learn more about our PointClickCare and MatrixCare integrations to avoid future paperwork.
Facility Name*
What State is your Facility In?*
Your Name*

First NameLast Name
Contact Number*
E-mail*
Resident's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is the Resident on Hospice?*

YesNo
Re-admission to United Wound Healing*

YesNoUnsure
Does the patient have a wound?

YesNo

Please upload the following files:
Most recent patient face sheet*

Browse Files

Cancelof
Reminder: If needed, please ensure provider EMR access has been setup for this patient.
Questions? If you have questions, please call us at 1-855-255-1750

Did you know we now have a direct interface with your EMR? Contact us to learn more about reducing paperwork and receiving our notes directly.
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New Patient Referral Form: