Request a Visit – DermaTech Mobile

We bring expert wound care directly to homes and care facilities. Fill out the form on this page to request a visit—it’s fast, simple, and secure.

Insurance Verification Request

Complete the form below

REFERRAL FACILITY CONTACT INFO

Facility name:

Contact phone:

Contact email:

PATIENT DEMOGRAPHIC AND INSURANCE INFORMATION

PATIENT NAME:

PATIENT DOB:

PATIENT ADDRESS:

CITY, STATE, ZIP:

PATIENT PHONE:

PATIENT FAX/EMAIL:

PATIENT CAREGIVER INFO:

PRIMARY

INSURANCE NAME:

POLICY NUMBER:

PAYER PHONE:

PROVIDER STATUS:

IN-NETWORK

OUT-OF-NETWORK

SECONDARY

INSURANCE NAME:

POLICY NUMBER:

PAYER PHONE:

PROVIDER STATUS:

IN-NETWORK

OUT-OF-NETWORK

DO WE HAVE YOUR PERMISSION TO INITIATE AND FOLLOW UP ON PRIOR AUTHORIZATION?

YES

IS THE PATIENT CURRENTLY IN HOSPICE?

YES

IS THE PATIENT IN A FACILITY UNDER PART A STAY? IF YES, PART B SERVICES CANNOT BE BILLED

YES

IS THE PATIENT CURRENTLY UNDER A POST-OP GLOBAL SURGICAL PERIOD?

YES

IF YES, PLEASE LIST CPT CODE(S) OF PREVIOUS SURGERY:

SURGERY DATE:

LOCATION OF WOUND:

LEGS/ARMS/TRUNK ≤ 100 SQ CM
15271/15272

LEGS/ARMS/TRUNK ≥ 100 SQ CM
15273/15273

FEET/HANDS/HEAD ≤ 100 SQ CM
15275/15276

FEET/HANDS/HEAD ≥ 100 SQ CM
15277/15278

ICD-10 CODES:

TOTAL WOUND SIZE AND / OR MEDICAL HISTORY:

ADDITIONAL NOTES:

Insurance Verification Request

REFERRAL FACILITY CONTACT INFO

PATIENT DEMOGRAPHIC AND INSURANCE INFORMATION

PRIMARY

SECONDARY

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