Preferred Medical Network - One Source. Many Solutions.

Preferred Medical Network Discharge Referral Form

Phone 1-888-586-4650 or Fax 502-489-5045
Email mse@preferredmedical.net

Please complete this entire form.
Items in red are required

Patient Information
Language:   English   Spanish   Other: 
Name: Sex: F
Address: Date of Birth:
City/State: Date of Injury:
Zip Code: Claim #:
Social Security #: Employer:
Telephone: Diagnostic Code:  
Specific Injury Or Condition:
Procedure Being Done:
Admission Date:
Estimated Date of Discharge:
Name of Person Filling Out this Form
Name:
Email:
Company:
Telephone: Ext.
Carrier/Billing Information
Carrier Name:
Branch:
Adjuster:
Phone:
Email:

Authorized Physician
Physician Name:
Phone:
DEA #:
Treating Facility
Facility Name:
Phone:
Discharge Planner:
Comments or Descriptions:
File Attachment:
 
Attach a digital copy of any documentation to this form. Microsoft Word, Plain Text, PDFs, JPEGs, TIFFs and GIFs accepted.
File size must be 5 MB or smaller.

 
Please choose a file: