The Wound Care Resources Order Form

simple, organized and easy-to-use

Click here to download the order form and fax to the office at (877) 287-2007
OR
Scroll down, fill out the form below to automatically email the order to our office.


Click on the topics below for more detailed information.

Filling Out the Wound Care Resources Order Form

Common ICD9 Codes

Wound Information

Spaces must be filled in and correct choices marked (circled on paper form or checked on emailable form). This information is required by Medicare and other insurance companies. 

Customized Dressing Order

Style, drainage and units/month are given for your information only and are determined by Medicare. Our office will send the correct dressing size based on the wound measurements given. Drainage and  units/month guidelines indicate which products you may combine based on drainage and how often the dressing needs to be changed.  

Place check marks going down the product list beside the dressings desired for each numbered wound site.

Signatures

WCR must have the patient's signature as well as the physician's name, signature and NPI number in order to bill insurance. WCR will obtain doctor and patient signatures for orders emailed to us from this site.
It is imperative to determine if a nurse/physical therapist is coming into the home for ANY reason.
Patient is receiving home health OR outside assistance in the home: Yes No
 
  Contact Email:   (We will send confirmation upon receiving your order)
  Patient Name:   Patient Phone:
  Doctor Name:   Doctor Phone:
  Facility Name:   Doctor Fax:
  Your Name (Clinician):   Date:
 
 
REQUIRED WOUND INFORMATION
Mark all choices and fill in spaces - all fields are required for each wound section per wound

Wound Stage		 Wound 1
II III IV
P F Un 		Wound 2
II III IV
P F Un 		Wound 3
II III IV
P F Un 		Wound 4
II III IV
P F Un
ICD9 Code
Size LxWxD
in centimeters 		L W D L W D L W D L W D
Location
ex: L lower leg
Drainage min mod heavy min mod heavy min mod heavy min mod heavy
Ever Debrided? yes no yes no yes no yes no
Duration of Need 30 60 90 30 60 90 30 60 90 30 60 90
Frequency qd qod wkly qd qod wkly qd qod wkly qd qod wkly
 
 
 
CUSTOMIZED DRESSING ORDERS
Please check all products you wish to receive, for up to 3 wounds
Wound
1      2      3      4		 Product Style Drainage
Requirement		 Units/Mo.
Requirement
Calcium Alginate 2x2, 4x5, 3/4x12 mod-heavy up to 30
Silver Alginate 2x2, 4x5, 3/4x12 mod-heavy up to 30
Medihoney Alginate 2x2, 4x5, 3/4x12 mod-heavy up to 30
Anasept Gel 3 oz tube no min 3 oz
Silver Sept Gel 1.5 oz, 3 oz tube no min 3 oz
Hydrofera Blue 2x2, 4x4 mod-heavy up to 12
Collagen 2x2, 4.34 sq in any up to 12
Non-Adherent Dressing 3x3, 3x8 any up to 30
Transparent Film 2x3, 4.25x4.25, 6x8 any up to 12
ABD Pad 5x9, 8x10 mod-heavy up to 30
Algidex AG Foam 2x2, 4x5 mod-heavy up to 12
Bordered Foam 1.6x2, 3x3, 4x4, 6x6 mod-heavy up to 12
Antimicrobial Gauze 4" roll any up to 30
Gauze Roll 4" bulky roll any up to 30
Conforming Gauze Roll 2", 4" any up to 30
Antimicrobial Gauze Sponge 2x2, 4x4 any up to 30
Paper Tape 1", 2", 3" any 2 rolls/wound
Transparent Tape 1", 2", 3" any 2 rolls/wound
Silk Tape 1", 2", 3" any 2 rolls/wound
Retention Tape 2", 4", 6" any 1 roll/wound
 
 
If you prefer a certain brand or product, please list them here. If we cannot provide what you have requested, we will contact you immediately.

Available for purchase only - no S&H with above order
Check below if you would like your patient to receive this product. This item is not billable to insurance. We will contact your patient for billing and payment information.

ANASEPT SPRAY 8 oz pump: $11 12 oz trigger: $14
 
Click below to submit the order to WCR.

If you would like to include Patient Demographics with this order, you will be prompted to do so in the next step.

This next step is not required: you may FAX the demographics to (877) 287-2007 after clicking below.
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