United Wound Healing New Patient Referral Form 2018-2025 free printable template

New Patient Referral Form PLEASE NOTE: Completed form must be received 72 hours prior to Wound Rounds to ensure patient registration and insurance authorization occurs. Please scan and email this

How to fill out new patient referral form

How to fill out United Wound Healing New Patient Referral Form

1. Obtain the United Wound Healing New Patient Referral Form from the clinic's website or reception.
2. Fill in the patient's personal information, including name, date of birth, and contact details.
3. Provide the referring physician's information, including name, phone number, and any other required details.
4. Include the patient's medical history relevant to wound care, such as previous treatments and existing conditions.
5. Specify the type of wound and any relevant description to assist in the assessment.
6. Sign the form to authorize the referral and include the date.
7. Submit the completed form according to the clinic's instructions, either electronically or via fax/mail.

Who needs United Wound Healing New Patient Referral Form?

1. Patients who have chronic or non-healing wounds.
2. Referring physicians who require specialized wound care for their patients.
3. Individuals seeking evaluation for complex wounds or conditions related to wound healing.

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What is United Wound Healing New Patient Referral Form?

The United Wound Healing New Patient Referral Form is a document used by healthcare providers to refer patients to United Wound Healing for evaluation and treatment of wound-related conditions.

Who is required to file United Wound Healing New Patient Referral Form?

Healthcare providers, such as primary care physicians or specialists, are required to file the United Wound Healing New Patient Referral Form when they believe a patient needs specialized wound care.

How to fill out United Wound Healing New Patient Referral Form?

To fill out the United Wound Healing New Patient Referral Form, the referring provider must provide patient information, medical history, details about the wound, and any relevant lab results or imaging studies.

What is the purpose of United Wound Healing New Patient Referral Form?

The purpose of the United Wound Healing New Patient Referral Form is to facilitate the efficient transfer of patient information from the referring provider to United Wound Healing, ensuring appropriate and timely wound care.

What information must be reported on United Wound Healing New Patient Referral Form?

The information that must be reported on the United Wound Healing New Patient Referral Form includes the patient's demographic details, medical history, description of the wound, previous treatments, and the referring provider's information.