For referring providers

Referral form

Print this page, fill it in, and fax it to (888) 507-7136. Or call (480) 940-7676 and we'll take it over the phone — usually faster.

Call it in instead

Fax, don't email. This form asks for patient information. Fax is a covered channel; ordinary email is not. Please don't scan this and send it to a regular inbox.

Choice Healthcare, Inc. Durable Medical Equipment · Arizona & Nevada

500 N. 56th Street, Suite 10, Chandler, AZ 85226
P (480) 940-7676 · F (888) 507-7136

DME & Wound Care Referral

Patient

NameDOB

Address

City / State / ZIPPhone

Height / WeightCaregiver & phone

Insurance

Primary planID #

Secondary planID #

Ordering practitioner

NameNPI

Practice / facilityPhone

FaxBest contact

Date of last face-to-faceDischarge date, if applicable

Equipment requested — check all that apply

Power wheelchair — Group 1 / 2 / 3 Custom manual — ultralight / tilt-in-space Standard or transport wheelchair Scooter / POV Semi-electric hospital bed Pressure-redistribution surface Negative pressure wound therapy Surgical dressings Compression / lymphedema garments Orthotic bracing Diabetic shoes & inserts Walker / rollator / commode Other __________________________

Clinical summary

Primary diagnosis / ICD-10

Mobility limitation & effect on daily activities in the home

If wound care — type, location, stage, measurements (L × W × D), duration

Treatment already tried

Records attached — check what you're sending

Face-to-face / chart note Standard Written Order Patient face sheet / demographics Insurance cards, front & back PT / OT evaluation Wound assessment notes History & physical Nothing yet — please help us assemble it

Send whatever you have. A referral with nothing attached is still a referral — our representative will collect the rest with you.

Signature

Referred byTitle

SignatureDate

Fax to (888) 507-7136 · Questions: (480) 940-7676 · choicehcsupply.com This document may contain protected health information. If you received it in error, please notify us and destroy it.

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