Date of Birth:
Zip Code:
Zip Code:
Primary Phone #: Secondary Phone #: Other:
Referring Physician: Phone #: Fax #:
___YES ___NO
Agency Name: Body part injured: Date of Injury:
Claim #: Adjustor Name: Adjustor Phone #:
Primary Insurance: Subscriber: Sub ID:
Secondary Insurance: Subscriber: Sub ID:
Tertiary Insurance: Subscriber: Sub ID:
# of wounds:
___YES ___NO
___YES ___NO
___YES ___NO
Name of surgeon: Date of surgery: CPT Code(s):
The WCC is not for dressing changes. Patients admitted to the WCC are assessed & treated by the wound care physicians.
Is English the patient's primary language? ___YES ___NO , if no, please indicate primary language:
Location: Queen's Medical Center - Wound Care Center | Phone 808-691-5496 | Fax 808-691-5011
Primary Providers: Robert Aki, DPM | Ajay Bhatt, MD | Susan Hiraoka, DPM | Michael Shin, MD | Patrick Katahara, PA-C
Consults: Robert Kistner, MD | Vincent Nip, MD | Erik Kajioka, MD | James Joyner, MD | Heath Chung, MD | Ramy Badawi, MD | Jon Dworkin, MD
For services (CPT Codes): 97597, 97598, 97602, 11042 -11047, 11100, 29580, 29581, 29445, 93922, 93923
Many insurance plans require prior authorization and/or physician referral which may take up to 14 days. If the patient
needs to be seen earlier, please indicate: ___ URGENT ___ Routine ____CHOW
Today's date:
Patient's Name:
Current Address:
Mailing Address (if different from above):
Needed Documentation
Is the patient able to ambulate independently? ___YES ___NO
Worker's Compensation / No-Fault Insurance Claim
Is the illness / injury covered by a Worker's Compensation or No-Fault claim?
Health Insurance Information
Diagnosis and Pertinent Medical History
ICD-10 diagnosis codes:
Wound location(s):
If the wound is on an extremity, is patient being seen by a vascular surgeon?
If YES, is the vascular surgeon aware of and approve of this referral?
Is the wound on a surgical site (ie amputation stump)?
*Please inform us if patient has a history of the following: ___ MRSA ___ VRE ___ ESBL ___ C. Diff
Please ensure that patients are not admitted to or discharged from the hospital or scheduled for surgery on the same day as WCC visit
History & physical or clinical documentation that includes the following information (IF AVAILABLE):
1. Wound location(s),size(s), and duration:
2. Previous treatments that have been tried:
3. A statement saying the patient is being referred to the Wound Care Center:
4. Labs/imaging in the past 2 months, particularly Prealbumin, A1C, and vascular studies:
Thank you for your referral! Should you have any questions, please do not hesitate to call us at 808-691-5496