Preferred Medical Network - One Source. Many Solutions.

Preferred Medical Network Referral Form

Phone 1-888-586-4650 or Fax 502-489-5045

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: Type of Injury:
Social Security #: Jurisdiction:
Telephone: Claim #:
Employer/Group: Diagnostic Code:  
Name of Person Filling Out This Form:
Name: Email:
Company: Telephone: Ext:
 
Carrier/Billing Information
Carrier Name: Contact:
Address: Telephone: Ext:
City/State:    
Zip Code:    
Employer at Time of Injury
Employer: Telephone: Ext:
Address:    
City/State:    
Zip Code:    
Nurse Case Manager Information
NCM:    No NCM on File
Company: Email:
Address: Telephone: Ext:
City/State: Fax:
Zip Code: Cell:
Treating Physician Information
Name: Next Appt Date:
Address: Office Phone: Ext:
City/State: Fax:
Zip Code: Misc:
Doctor Wants Films:   Yes   No   ?: 
Type of Exam
MRI
MRI W/Contrast
MRI W/WO Contrast
CT
CT W/Contrast
CT W/WO Contrast
EMG
NCV
EMG/NCV
Other:
 
Body Part
Right
Left
Bilateral
N/A
Other:
 
Authorized Services
Tens/Electrotherapy:
Purchase  Rental
 
Supplies:

 
Type of Unit Currently in Use:
 
Prescriptions:
Drug Card Mail Order
    30 Day 60 Day 90 Day Indefinitely Other:
 
Maintenance Supplies:
TENS Supplies Ostomy Respiratory In-Home Health Other:
 
Pharmacy: Telephone: Ext:
Authorized Meds: Authorized Prescriber:
Previous Supplier:    
Durable Medical Equipment
Wheelchair
Hospital Bed
Braces
CPM Machine
Bone Stimulator
Other: 
Comments or Descriptions: Rush
File Attachment:
 
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Total file size must be 5 MB or smaller.

 
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