San Antonio Intake

Referring Facility

Date

Contact

Phone

Fax

Patients Primary Care Provider

Patient Information

Patient Name

DOB

Address and phone of where patient currently resides.

Address

City

Zip

Phone

Primary Insurance (Medicare is primary for our billing)

Policy #

Secondary Insurance

Policy #

Does patient reside in a Skilled Nursing Facility?

No If yes, under 100 days If yes, over 100 days

Does patient have Home Health?

Yes No

Wound Information

Please submit documentation of the standard wound therapies provided. Per insurance requirements, standard therapy must be tried prior to our advanced therapy treatment.

Please complete all the following wound information and attach wound care chart notes.

Wound Location

ICD-10 Code(s)

Wound Size: (cm LxWxD) - (Must be greater than 1cm)

How long has patient had the wound? (must be more than 30 days)

Has the wound size improved by more than 50% in the last 30 days?

Comments: (Please list or include any comorbidities that may affect wound healing)

Please upload recent Progress Note and Medications List

Add file

Please upload a file

Please upload patient's insurance and license info

Add file

Please upload a file

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