CONTACT US | directcaremanagement

Complete the below referral form, and someone from the Direct Care Management Concierge Team will be in contact with you shortly!

Should you have any questions or need assistance, please email us.

1.888.478.4264

phone

1.888.413.0267

fax

referrals@directcaremanagement.com

12150 Tributory Point Drive, Suite 200

Gold River, California 95670

address

REFERRAL

Patient or Employee Information:

Last Name

First Name

Middle Initial

Date of Injury

Date of Birth

Claim Number

Policy Number

Phone Number

Employer

Alternate Phone Number

Height

Weight

Surgery Authorization Number

Date(s) of Hospital Stay/Duration

Requesting Physician Information:

Physician Name

Practice Name

Contact Name

Address

City

State

Zip Code

Phone Number

Fax Number

Specialty

NPI Number

Tax ID Number

Facility Information:

Facility Name

Contact Name

Phone Number

Fax Number

Tax ID Number

Claims Administrator Information:

Company Name

Contact Name

Address

City

State

Zip Code

Phone Number

Fax Number

Requested Treatment Information:

Diagnosis Codes

ICD-10 Codes

Service/Good Requested

CPT/HCPCS

Other Information (Frequency, Duration, Quantity)

Anesthesia Time

DVT

Yes

Additional Information:

RFA

Upload File

PR1 and PR2

Upload File

Physician Chart Notes

Upload File

Additional Comments

Thank you for submitting!

Someone from the Direct Care Management Team will be in contact with you soon!