Refer a Patient for Mobile Wound Care

Request referral coordination for mobile wound care. Review the required records and confirm an approved secure transmission method with our team before sending clinical documents or wound photos.

For authorized referring providers 24-hour coordination inquiries

Check service coverage by ZIP code

Explore listed service regions. Confirm the exact address and visit availability with our team.

Notice: This form is intended for use by referring healthcare providers, discharge planners, and case managers. If you are a patient or family member seeking care, please use our Patient Intake Form instead.

Records to prepare for your referral

Patient face sheet: Include patient demographics, contact information and insurance information.
Referral for wound evaluation and treatment: Include the referring clinician's referral and contact information. The organization agreement does not replace a required clinical order or patient authorization.
Wound care progress notes, when applicable: Send the past 30 days of wound care progress notes if the patient has been under your organization's care for more than 30 days, or has received wound treatment from any provider during the past 30 days.
Recent wound photos, if available: Include recent wound photos if available and permitted to be shared. Add the date taken and wound location when known. Photos are optional and do not replace an in-person clinical assessment. Do not delay a referral solely because photos are unavailable.

Patient records and wound photos must be submitted separately from the organization agreement. Verify the destination, share only information lawfully disclosed for the referral, and use your organization's approved secure transmission method. Do not assume an ordinary email message is secure. Call our coordination team if you need transmission instructions.

View the complete Healix360 referral instructions

Referral Information

Please complete all required fields to ensure rapid processing.

Referring Provider Information

Provider Name *

Provider NPI

Practice / Facility Name *

Contact Person (if different)

Contact Phone *

Contact Fax

Contact Email *

Patient Information

First Name *

Last Name *

Date of Birth *

Patient Phone *

Home Address / Facility Location *

City *

Zip Code *

Primary Insurance *

Insurance ID Number

Clinical Information

Primary Wound Type *

Urgency *

Brief Clinical Notes / Description *

Supporting Documentation:

Send the face sheet, wound evaluation referral, applicable progress notes and recent wound photos if available through your organization's approved secure method. Verify the destination and follow your organization's privacy procedures for cover sheets and attachments.

By submitting this form, you attest that you are an authorized healthcare representative and have obtained necessary consents to share this Protected Health Information (PHI) for the purpose of care coordination.

You Don't Have to Live With a Wound That Won't Heal

Get connected with an experienced wound care specialist today and take the first step toward healing. Most treatments are covered by Medicare Part B.

Find a Provider Near Me Call Now