WOUND GENIUS REFERRAL FORM
Date
Referring Agency
Patient’s Name
Date of birth
Patient
New Patient
Established Patient with New Wounds
Where
Hospice
Home Health
Other
Patient Location Type
Skilled Nursing Facility (SNF)
Assisted Living
Home
Other
Patient Location Address
Has the patient had a recent hospitalization in the past 100 days?
Yes
No
Date of discharge from hospitalization
Does the patient has Secondary Insurance?
Yes
No
If yes, please provide a copy of the front and back of the secondary insurance card
You Can Upload 2 files
Diabetic
Yes
No
Diabetic Type
Type 1
Type 2
Case Manager Name
Case Manager Contact
Power of Attorney Name
Power of Attorney Contact
*
Number of Wounds
Wound Locations & Duration
Where do you want to receive the Medical Records?
Email
Fax
Email
*
Fax
Please attach a face sheet, wound photos, medication list, insurance cards and any other information if possible
You Can Upload Multiple Files
Submit