PATIENT REFERRAL FORM – Healing Hands

FACILITY INFORMATION

Facility Name *

Address *

Phone *

Facility Contact Person *

Phone *

Ext *

Email *

PATIENT INFORMATION

Name *

Date of Birth *

Address *

Phone *

Email *

POWER OF ATTORNEY (POA)

Does this patient have a POA? * YesNo

Name of POA *

Phone Number *

CURRENT PROVIDERS

Is this patient currently seeing any other providers, including Home Health? * YesNo

If yes, please provide facility name and contact information:

Facility Name *

Contact Person *

Phone *

Email *

REFERRAL DETAILS

Reason for Referral * Wound Description * DX Code *

REQUIRED DOCUMENTS

Please include the following documents with this referral:

Patient Demographic Page *

Insurance (Primary & Secondary) – include copy of insurance card *

Hospital Records *

PCP Encounter Notes *

Home Health Encounter Notes *

Recent Labs *

Imaging Records *

Wound Photos (with size if available) *

DOCUMENT SUBMISSION OPTIONS

You may submit documents using any of the following methods:

Email: abailey@healinghandsmpg.com

Fax: 888-698-8617

(Attach all required documents when submitting via email or fax)

NOTES

Thank you for choosing Healing Hands mobile physicians group to assist with your wound care needs. We value strong communication with our referral sources to work together in developing the best possible outcomes to promote healing and overall patient care.