Discharge Referral Form – Preferred Medical

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

Please complete as many fields as possible. Note that required fields are indicated below.

Preferred Medical Discharge Referral Form

This field is for validation purposes and should be left unchanged.

Patient Information

Language

English

Spanish

Other

Sex

Male

Female

Patient Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Date of Injury(Required)

Type of Injury

Claim Number(Required)

Employer

Patient Phone

Diagnostics Code

Specific Injury or Condition

Procedure Being Done(Required)

Admission Date

Estimated Date of Discharge

Submittor Information

Name(Required)

First Last

Email(Required)

Company(Required)

Phone(Required)

Carrier/Billing Information

Carrier Name(Required)

Branch

Adjuster(Required)

Phone(Required)

Authorized Physician

Physician Name

Phone

DEA Number

Treating Facility

Facility Name

Phone

Discharge Planner

Comments/Description

Additional Information

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