Refer a Patient

This form is securely submitted and in HIPAA compliance
*Required for Dispensing Order

1. Contact Information
Referral Sent By:*
Email that relates to sent by*
Referring Provider's Name*
First Last Title (M.D., D.O, etc)
Provider Fax #
Your Organization*
Provider Phone Number*
2. Patient Information
Patient Name*
First Last
Patient Date of Birth*
MM
DD
YYYY
Patient Phone Number*
Patient Email Address
Patient Address*
Street Address Address Line 2 City State ZIP Code
Primary Contact Information
- Same as Patient
Primary Contact's Name
First Last
Primary Contact's Phone Number
Primary Contact's Email Address
3. Insurance Information
Please include patient's insurance or drop demographic sheet below
Medicare #
Medicaid #
Managed Care or Commercial Plan Name
Member Number #
Upload Most Recent Progress Note & Patient Demographic sheet
Drop files here or
Provider NPI Number*
Please select one diagnosis code*
If you selected "other," please provide diagnosis code below*
4. Supplies Needed
What type of catheter does your patient need?*
- Intermittent Urinary Catheter Straight tip (A4351)
- Intermittent Urinary Catheter Coude tip (A4352)
- Intermittent Urinary Catheter with Insertion Supplies (A4353)
- Sterile Lubricant Packet (A4332)
Please select at least one option.
Additional Products/Comments
Dispensing Order Start Date (Needed for Dispensing Order)*
MM
DD
YYYY
Length of Need/Refills (months)*
Frequency (Times/Day)*
Quantity (Times/Month)*
French Size*
5. Working with MaxWell Medical Services
How did you hear about us?
Signature*
Date Signed*
MM
DD
YYYY

1. Contact Information