180 Medical E-Script Referrals Portal

Facility

Company / Practice Name *

Practice EMR System

Address Line 1 *

Address Line 2

City *

State *

Postal Code *

Phone *

Fax *

Field Consultant

Patient Info

Patient First Name *

Patient Last Name *

Patient Phone *

DOB *

Age

Patient Primary Insurance Name

Patient Primary Insurance ID #

Patient Primary Insurance Phone #

Patient {{IsPodRequest ? "Supplemental" : "Secondary"}} Insurance Name

Patient {{IsPodRequest ? "Supplemental" : "Secondary"}} Insurance ID #

Patient {{IsPodRequest ? "Supplemental" : "Secondary"}} Insurance Phone #

Type of Supplies Needed *

Urological Supplies

Product Type *

FR / Intermittent Size

Tip Type

Individual Lube Packets

External Size

Foley Size

Balloon

Tip and Material Type

Product Details (HCPC, Name, and/or Description) *

Quantity *

90 Day Supply

Number of Refills

Ostomy Supplies

Ostomy Type *

Product Reference Number

Diagnosis Code *

Other Diagnosis

Surgery Date

Reversal Anticipated?

90 Day Supply *

Number of Refills *

Order Comments

Referrer / Physician Information

Physician First Name (Uppercase enforced) *

Physician Last Name (Uppercase enforced) *

Nurse / M.A. Name *

Date

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