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Arizona – New Patients & Referral Form

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New Patients - Arizona

Our Arizona wound team is local to the area and delighted to bring compassionate, skilled wound care to the people in their communities.  Below, you will find our general referral guidelines as well as our online new patient intake form. 

Our Arizona location is currently providing care in Maricopa County.  Some cities include: Phoenix, Buckeye, Scottsdale, Litchfield, Sun City, Good Year and Surprise.  Please contact us to inquire if we are scheduling in your city.

Our primary patient has Medicare, Part B coverage.  We do not require a medical referral but we do require our new patient intake form be completed in full.  Once we receive the new patient referral, we will confirm insurance eligibility and the complete prior authorizations.

We look forward to being a dedicated part of your health care team.

Referral Guidelines:

  • Patients with non-healing wounds that have been present for more than 4-6 weeks.
  • Patients with open wounds that measure 1cm or greater.
  • The wound size has not reduced by more than 50% in the last 30 days.
  • Our primary patient has Medicare, Part B insurance

Insurance Clarifications

  • We are not considered home health and bill under Medicare, Part B.
  • Patients with traditional Medicare, Part A and Part B, can receive home health and our specialized wound care services simultaneously.
  • A Medicare ID number always starts with a numeric number, followed by a letter and is 11 digits long.  Example:  1EG4-TE5-MK72.
  • Medicare Advantage Plans will not cover our treatment plan.

How to refer a patient:

  1. Complete the new patient referral form below. The online form will automatically download to our office via a HIPAA compliant format. If you are unable to complete our online form, please contact our office and we will email or fax you a printable format.
  2. Provide the latest progress notes that include current medications and any relevant laboratory results.
  3. If you are unable to upload progress notes via our Secure Form, please fax the documents.
  4. Once authorization is approved, your patient will be called to schedule a new appointment. Authorizations typically take 48 hours.

New Patient Intake Form

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