REFERRAL FORM

Phone

(866) 363-7847

Website

http://www.intermedccs.com

Fax

(866) 262-2662

Your Name:	Title/Position:
Date:
Company:
Address:
City/State/ZIP:
Phone:	Ext: Fax:

BILLING INFORMATION

Company:	Tax I.D. (if applicable):
Contact:
Address:
City/State/ZIP:
Phone:	Ext: Fax:

CLAIMANT INFORMATION

Name:	SSN:
Address:
City/State/ZIP:
Phone:
Cell Phone:	Pager:
Claim No.:	DOI: DOB:
Employer:
Injury/Diagnosis:

PHYSICIAN INFORMATION

Prescribing Physician:
Address:
City/State/ZIP:
Phone:	Fax:

TYPE OF EQUIPMENT REQUESTED

Prescription Obtained: Yes No

DELIVERY ADDRESS (if different from above)

Name:	Contact:
Address:
City/State/ZIP:
Room No.:
Phone:	Fax:

TRANSPORTATION REQUESTED

Appt. Date:	Appt. Time:
Facility/MD Name:
Address:
City/State/ZIP:
Phone:	Fax:

PICK UP ADDRESS (if different from above)

Room No.:	Contact:
Bed No.:
Facility:
Address:
City/State/ZIP:
Phone:	Fax:

NURSING/HHA/HOUSEKEEPING REQUESTED

Start Date:	Duration:
Service Requested:

SPECIAL ORDER REQUEST



DMEQUIP: (866) 363-7847	http://www.intermedccs.com	Fax: (866) 262-2662