PCA Provider Form for Patient Matching

Welcome, valued PCA provider! Your information here helps our system accurately match your practice with incoming patient referrals.

Practice Name *

Practice Location *

Street Address

*

Postal / Zip Codes

What is your service area? Please list counties or zip codes *

ex) Los Angeles county, Ventura county, Monterey county, San Bernadino county, Santa Barbara county,... or 90001, 90005 90009, 90013, 90016,....

How many providers are within your group? What licensures? *

ex) 1 MD, 3 NPs. 2 LPNs ...

What are your providers' primary specializations relevant to wound care? *

ex) Pressure Ulcers, Surgical Wounds, Podiatry, Vascular Surgery, Dermatology, ...

What types of insurance do your providers accept? *

ex) Medi-Cal, Medicaid, Blue Cross, Aetna, ...

Any additional notes or information about your practice? *

ex) We only service San Bernadino on Tuesdays and Thursdays

My team will have visit notes ready within: *

ex) Within 24 hours of visiting the patient

My team will visit the patient within: *

ex) Within the same work day as receiving the referral

I verify that the information provided is accurate and I will adhere to the time standards that I have provided.