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

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Services
Providers

Column 2

Company
- Overview
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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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Time the Driver dropped the IW off at the facility.

Time the IW loaded into the vehicle for the return.

Wait time must be authorized on the Authorization Confirmation document that you received from ProCare's Dispatch team in order to invoice for it. Enter the total time the driver waited at the facility.

Wait time must be authorized on the Authorization Confirmation document that you received from ProCare's Dispatch team in order to invoice for it. Enter your Per Hour rate, not the total wait time cost. Wait time must be entered separately from other fees.

Flat Rate fields should be used only if this trip was quoted as a Flat Rate on the Authorization Confirmation document you received from ProCare's Dispatch team. Do not enter mileage if invoicing a flat rate. If the service was sent at your contracted Per Mile rates, please use the Total Mileage and Per Mile Rate fields.

Enter the total loaded miles for the trip. Only enter miles driven while our passenger is in the vehicle.

Enter your contracted, or agreed upon, per mile rate. For your Contracted Per Mile rate, please refer to your Fee Schedule that was approved by Provider Relations. If you require a copy of your approved Fee Schedule please contact Provider Relations.

Other fees will include Wheelchair Load Fees, Parking Fees, Tolls, Additional Passenger fees, etc. These fees should be authorized on the Authorization Confirmation document you received from ProCare's Dispatch team. Enter the total dollar amount of the extra fees and place a breakdown in the Other Fee Details section.

Enter your total Contracted Minimum Mileage for the referral. For your Contracted Minimum Mileage, please refer to Min Trip on the Fee Schedule that was approved by Provider Relations. Multiply the Min Trip miles by the number of loaded legs on the referral. (Round Trip = Min Trip Miles x 2). If you require a copy of your approved Fee Schedule please contact Provider Relations.

This is the total dollar amount requested for reimbursement. This amount is not guaranteed and may be adjusted. If adjusted, you will receive an explanation with the reason for the change.