Online Clinical Submission

Physician & Clinical Alert: Fast-Track a Patient

Use this secure form to Fast-Track a patient and have our team initiate insurance authorizations immediately.

Referring Office/Clinic

Patient Info Name/DOB/

Wound Care Referral

Wagner Grade 2 Diabetic Ulcer (E11.621) – Deep ulcer to tendon/capsule, no bone involvement.

Venous Stasis Ulcer (I83.819)

Pressure Injury, Stage 3/4 (L89.xxx)

Other

Short answer

Urgent HBOT Referral

Compromised Skin Graft or Flap: T86.828

Calciphylaxis (Urgent Evaluation): E83.59

HBOT Limb Salvage Referral

Wagner Grade 3+ Diabetic Ulcer (E11.621 + L97.xxx) – Osteomyelitis/Abscess suspected.

Failing Flap or Graft (T86.828)

Chronic Osteomyelitis (M86.1)

Non-healing Wound (>30 days with <50% closure)

Pressure Injury (Stage 3/4): L89.xxx

Surgical Wound Dehiscence (Incision Opening): T81.31XA

HBOT Radiation Injury Referral

Radiation Cystitis (Chronic Hematuria): N32.81

Radiation Proctitis (Rectal Bleeding/Pain): K62.7

Osteoradionecrosis (Bone Damage from Radiation): M84.88 (General) or M27.2 (Mandibular/Jaw)

Soft Tissue Radionecrosis (Radiation Injury to Skin/Tissue): L59.8

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