Philadelphia Wound Care
info@philadelphiawoundcare.com
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8:00 AM - 7:00 PM
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Wounds
Venus & Vascular Ulcers
Diabetic Wound & Ulcer Care
Pressure Ulcers & Bedsores
Chronic & Non-Healing Wounds
Post-Surgical Wound Care
Services
allograft & Regenerative Therapy
Advanced & Complex Wound Care
Mobile In-Home Wound Care
Post Acute & Hospital Discharge Wound Care
Skilled Nursing & Long-Term Care Facilities
For Providers
Referrals & Consults
Online Provider Referral Form
Download Provider Referral Form
Patient Resources
Philadelphia Wound Care FAQs
Wound Care Medical Group
Senior & Home Health Wound Care
Physician House Calls
Mobile & In-Home Wound Care
Advanced and Complex Wound Care
Hospital & Health System
Contact Us
Home
Wounds
Venus & Vascular Ulcers
Diabetic Wound & Ulcer Care
Pressure Ulcers & Bedsores
Chronic & Non-Healing Wounds
Post-Surgical Wound Care
Services
allograft & Regenerative Therapy
Advanced & Complex Wound Care
Mobile In-Home Wound Care
Post Acute & Hospital Discharge Wound Care
Skilled Nursing & Long-Term Care Facilities
For Providers
Referrals & Consults
Online Provider Referral Form
Download Provider Referral Form
Patient Resources
Philadelphia Wound Care FAQs
Wound Care Medical Group
Senior & Home Health Wound Care
Physician House Calls
Mobile & In-Home Wound Care
Advanced and Complex Wound Care
Hospital & Health System
Contact Us
Call Anytime
(484)-531-6400
Provider Referral Form – Philadelphia Wound Care
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1) Referring Provider / Facility
Practice / Facility Name
*
Facility Type
Hospital
Skilled Nursing Facility (SNF)
Home Health
Physician Office
Other
Referring Provider (Name, Credentials)*
*
NPI (optional)
Phone
*
Secure Email
*
Secure Fax
Preferred Contact Method
Phone
Secure Email
Fax
2)Patient Information
Patient Full Name
*
DOB
*
Patient Phone
*
Emergency Contact Name
Emergency Contact Phone
Patient Address (Street, City, State, ZIP)
*
3) Insurance
Primary Insurance
*
Medicare Part B
Medicare Advantage
Medicaid
Commercial
Self-Pay
Insurance ID #
*
Secondary Insurance:
4) Wound Information
Wound Type:
Diabetic Foot Ulcer
Venous Stasis Ulcer
Pressure Injury
Arterial Ulcer
Surgical / Post-Op
Traumatic
Chronic / Non-Healing (>30 days)
Other
Pressure Injury Stage
Other Wound Type
6) Date: Notes
Wound Location(s)
*
Approx. Duration
< 30 days
1–3 months
3 months
Signs of Infection
Yes
No
Unknown
5) Prior / Current Treatment
Prior Wound Care?
Yes
No
Treatments Used
Standard Dressings
Debridement
Antibiotics
Negative Pressure / Wound VAC
Compression Therapy
Advanced Biologic / Allograft
Hyperbaric Oxygen
Other
Other Treatment
6) Requested Services / Urgency
Requested Services
Comprehensive Evaluation
In-Home Wound Care
Facility-Based Wound Care
Sharp / Surgical Debridement
Advanced Biologic / Allograft Therapy
Infection Management
Vascular Assessment
Ongoing Wound Management & Follow-Up
Urgency Level
Routine (within 7 days)
Urgent (48–72 hrs)
STAT / Same-Day
7) Clinical Notes
Clinical Notes (optional – include only relevant details)
8) Provider Attestation
Attestation Checkbox
*
I certify this referral is for treatment purposes under HIPAA (45 CFR §164.506) and the patient has been informed.
Provider Signature
*
Provider Signature (typed acceptable)
Date:
*
Submit
