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New Patient Referral

Step 1 of 9 - Referral Request

11%

Referral being requested by:
Name*
Phone*
Are you a family member or direct caregiver residing in new client's home?*
- Yes
- No
What is your relationship to client?*
Relationship and Business Name*
How did you hear about Charm Medical?*
- Save my info
Email
Password

Enter Password

Confirm Password

Patient Information
Does patient live at group home or assisted living environment?*
- Yes
- No
Name of assisted living or group home*
Patient Name*
Address*
City*
State*
ZIP Code*
Phone ( For Monthly Order Confirmation )*
Phone (Alternate)
Fax
Email
Date of Birth*

MM slash DD slash YYYY
Weight*
Height*
Diagnoses*
Patient Primary Language*
Does patient, or any other person in the residence, have a communicable disease?*
- Yes
- No
Please describe the communicable disease*

Insurance Information
Primary Policy ID#
Secondary Policy ID#
Mass Health Card ID#

Physician Information
Physician's Name*
Practice Name*
Address*
City*
State*
ZIP Code*
Phone*
Fax

For Group Homes, Assisted Living, etc
Patient Living in Group Homes, Assisted Living, etc...*
- Yes
- No
House Manager Name*
House Manager Phone*
House Manager Title
Is there a VNA in the home?*
- Yes
- No
VNA Name*
VNA Phone*

Primary Contact / Legal Guardian
Name*
Relationship*
Address*
City*
State*
ZIP Code*
Phone*

New Patient Information Packet
- Send packet to Fax
Fax*
- Send packet to Email
Email*
Is patient currently with another supplier?*
- Yes
- No
Company Name*
Supplies patient is receiving*
Is the patient requesting glucometer or diabetic supplies?
- Yes
- No
Has the patient received prior education about proper diabetic supply disposal methods?*
- Yes
- No
Has the insured been notified that supplies are being requested on their behalf and to expect a call from Charm?*
- Yes
- No

Supply Request
In space below, please list the supplies needed monthly. Be specific as to amounts needed per month, as well as sizes, styles, flavors, ounces, etc.*

Form Completion
PDF Upload
Accepted file types: pdf, Max. file size: 10 MB.
This form completed by*
Relationship*
Date

MM slash DD slash YYYY
Email

This field is for validation purposes and should be left unchanged.

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