General 3 — Elevat3 Wound Healing

New Patient Referral Form

Elevat3 Wound Healing will work together with your health care team, including home health, with the goal of healing your wound and improving your quality of life. We strive to streamline the referral and new patient process to get patients scheduled within a week.

While we accept most insurance plans, our primary patient has Medicare coverage. We do not require a medical referral but we do require the below information.

How to refer a patient:

1. Completed New Patient Intake Form below.

2. Recent Progress Notes that include medical history, wound care history and relevant lab results. If you are unable to complete our online form, please contact our office and we will email or fax you a printable format. (If you do not have access to this, a member of our wound team will work with your provider to retrieve this.)

Phone: 877-989-6552

Fax: 877-333-9985

Email: Info@Elevat3woundhealing.com

3. Once authorization is approved, your patient will be called to schedule a new appointment. Authorizations typically take 48 hours.

Appointment Guidelines:

Indications to Book an Appointment:

Patients with non-healing wounds that have been present for more than 4-6 weeks.
Patients with open wounds that measure 1cm or greater.
Patients with chronic wounds with nerve, tendon, bone or muscle exposed.
Patients with non-healing venous stasis ulcers, diabetic foot ulcers, arterial ulcers, neuropathic ulcers, pressure injuries (previously called pressure ulcers), vasculitic ulcers, scleroderma ulcers and surgical or traumatic wounds.
NEW PATIENT REFERRAL FORM

Referring Facility Name

Date

YYYY

Facility Contact

Facility Phone Number

(###)

###

####

Patients Primary Care Provider

Patient Information

First Name

Last Name

DOB

YYYY

Address and phone of where patient currently resides.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient's Phone Number

(###)

###

####

Primary Insurance (Medicare is primary for our billing)

Policy #

Secondary Insurance

Policy #

Does patient reside in a Skilled Nursing Facility?

If yes, under 100 days

If yes, over 100 days

Does patient have Home Health?

Yes

Wound Location

Please attach patient’s most recent medical chart notes to include: Medications, Medical History, Wound Info and COMPLETE ALL the following wound info:

Wound Size (cm LxWxD):

ICD-10 Code(s):

How long has patient had the wound?

Comments: (Please list or include any comorbidities that may affect wound healing)

Please email: - Recent Progress Note - Medications List - Patient's insurance - License info Info@Elevat3woundhealing.com or fax to 877-333-9985

New Patient Referral Form

How to refer a patient:

NEW PATIENT REFERRAL FORM