Patient Referral Form « ProCare

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- Patient Referral Form – old
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Thank you for choosing to refer your patient through the new and improved ProCare referral center. If you require additional assistance, call 866.941.7878 or email our form support team.

Patient Referral Form

Step 1 of 3

33%

User Information
*Required field. You must enter valid information for the fields required for your form to submit.
User Name*
First Last
Title
User Company*
Phone*
Fax
Email*
Payor Information
Payor Company*
Adjuster
Billing Address
Street Address Address Line 2 City State ZIP Code

Patient Information
Patient Name*
First Last
SSN
Patient Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Alt. Phone
DOB
MM slash DD slash YYYY
Height
Weight
Gender
- Male
- Female
Claim Information Diagnosis
Claim Number
Date of Injury
MM slash DD slash YYYY
Body Part
ICD9
Employer Info
Company Name
Contact Person
Employer Address
Street Address Address Line 2 City State ZIP Code

Services Requested
Transportation
- Ambulatory
- Wheelchair
- Non Emergency Stretcher
- BLS
- ALS
- Air Ambulance
- Commercial Flight
- Hotel
If you selected wheelchair, do you have your own?
- Yes
- No
Round Trip
- Yes
- No
Wait Time
- Yes
- No
Translation (please check all that apply)
- On-Site Interpretation
- Certified On-Site Interpretation
- Certified Legal Interpretation
- Video Remote Interpretation
- Conference Call
- Document
Language
Specify Other Language
Appointment Info
Appointment Date
MM slash DD slash YYYY
Appointment Time

: Hours

Minutes
Facility Name
Facility Telephone
Physical Address
Appointment Address
Street Address Address Line 2 City State ZIP Code
Special Instructions
Special Instructions
File Upload
Drop files here or

Max. file size: 32 MB.

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Column 1

Order Online
- Order Online
Services
Providers

Column 2

Company
- Overview
- Management
- Testimonies
- News & Events
- Careers
- Contact

Column 3

ProCare, Incorporated

Eisenhower Technology Park
4710 Eisenhower Blvd.
Suite C-4
Tampa, FL 33634

Tel:	866.941.7878
Fax:	813.769.3883

Column 4

Customer Service

Tel:	866.941.7878
Fax:	813.769.3883

customerservice@theprocare.com

Sales

Tel:	813.769.3880 x1145

sales@theprocare.com

Billing

billing@theprocare.com

Column 5

Current Employment Opportunities

If you are interested in joining our team, visit our application webpage by clicking the link below:

Join Our Provider Network

ProCare is always recruiting high-quality transportation and language providers to become part of our network. To begin the application process, visit our providers page by clicking the link below:

Column 1

ProCare, Incorporated

Eisenhower Technology Park
4710 Eisenhower Blvd. - Suite C-4
Tampa, FL 33634
Fax: 813.769.3883

866.941.7878

Toll Free Referrals

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