Wound Care Form Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form. Member’s ID #* Member's DOB* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Member's Name* First Last Error Message Provider InformationHospital/Facility NPI* 10 digitsHospital/Facility Name (where procedure will take place)* Error Message Ordering MD* Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Clinical InformationCPT Code(s) (Click + or - at the right to add up to 5 CPT Codes)*CPT CodeUnits Example CPT code: 12345Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Attach Clinical Information* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word filesSignature of Treating Physician*Signature Date:* For Diabetic Wound, please include the following: 30 Day Standard Wound Therapy Evidence of Osteomyelitis/Gangrene Documentation of Glucose control, Vascular Status and previous Debridement Wagner Classification Request Method*Request Method *StandardExpedited: By checking off Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision.Also, please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word filesSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA