Get Wound Care Center Inpatient Referral Form

Completing the Wound Care Center Inpatient Referral Form online is a crucial step in ensuring that patients receive timely and appropriate care. This guide will walk you through each section of the form, providing clear and supportive instructions to help you complete it accurately.

Follow the steps to successfully fill out the referral form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today’s date in the designated field to document when the referral is being made.
3. Indicate if this referral is to facilitate discharge from the hospital by selecting either YES or NO.
4. Provide the name and extension of the case manager responsible for the patient’s care.
5. Complete the patient’s name, date of birth, and current address along with the zip code to ensure accurate identification.
6. If the mailing address differs from the current address, fill in the mailing address and its corresponding zip code.
7. Record the primary and secondary phone numbers, and include any other relevant contact information.
8. Indicate whether English is the patient’s primary language, and if not, specify the primary language being used.
9. Enter the ordering physician’s name, phone number, and fax number to facilitate communication.
10. Include the primary care provider's (PCP) details for continuity of care.
11. Answer whether the patient can ambulate independently by selecting YES or NO.
12. If applicable, confirm whether the condition is covered by Worker's Compensation or No-Fault insurance by responding YES or NO.
13. Fill in the agency name, body part injured, date of injury, claim number, adjustor name, and adjustor phone number if related to Worker's Compensation.
14. Provide relevant surgical and medical history, including whether the patient is being seen by a vascular surgeon and if they are aware of this referral.
15. Specify if the wound is on a surgical site and provide the surgeon’s name and CPT code(s) related to previous surgeries.
16. Indicate any known history of specific infections such as MRSA or C. Diff.
17. Ensure necessary documentation is available, especially regarding wound details, previous treatments, and lab results from the past two months.
18. Once all fields are completed accurately, save your changes, and choose to download, print, or share the form as needed.

Start completing the Wound Care Center Inpatient Referral Form online today to ensure timely patient care.