Patient Referral Form

1

Patient Information

Patient's First Name *

Patient's Last Name *

Patient's Email *

Patient's Date of Birth *

Patient's Phone Number *

Patient's ID or Insurance Plan Policy Number *

Patient’s Insurance Plan Name *

Patient’s Insurance Type *

Injury Date (No-Fault or Worker's Comp) *

2

Equipment Selection

Select all equipment the patient requires. You can choose multiple items.

Diabetic Supplies

Incontinence Supplies

Shoes

Orthopedic Supplies

DME Equipment

OBGYN Supplies

COPD/Asthma Supplies

Miscellaneous

Other

3

Additional Information (Not Mandatory)

Street Address

Address Line 2

City

State

Zip Code

4

Physician Information

Physician’s First Name *

Physician’s Last Name *

Physician’s Number *

Physician’s Fax Number *

The documentation described below is not required for initial benefit verification.

Our team needs chart notes that demonstrate medical necessity. The medical records must contain sufficient information about the patient's medical condition(s) to substantiate necessity. Please provide the patient's diagnosis on the Rx.

Please upload the prescription (Rx) and relevant chart notes.

Drop files here or browse

Upload signed Rx or CMN — PDF or image, max 10MB No file chosen

Order Notes:

I agree to the Privacy Policy, Terms of Use, and to be contacted by ALFA HEALTH CARE SUPPLY, INC. regarding my interest in products and services.

Referrals

Patient Referral

Patient Referral Form

The documentation described below is not required for initial benefit verification.