What We Need to Process a Referral

1. Order Details

What you want to order and the patient’s measurements. If you’re unsure what’s appropriate, we’re glad to consult. Our fillable prescription form makes this simple.

2. Patient Demographics + Insurance

A face sheet or demo sheet with name, phone, DOB, and insurance information. Copies of insurance cards are helpful but not required if the information is complete.

Please include patient email (or a phone number that accepts text messages). Snail mail consents delay orders significantly. If email isn’t available, let us know up front.

3. Therapy Notes – for Compression items Only

Must include why the patient needs custom garments or accessories if ordering those. Therapy notes should include the stage of lymphedema and the clinical need to justify the garment.

Common justification phrases to include in your note:

• “Patient has poor containment with Ready to Wear garment”
• “Patient limb measurements do not fit into Ready to Wear garment”
• “Patient requires donning assist due to arthritis, weakness in hands”
• “Patient requires donning assist due to inability to reach feet for donning”

Need more examples? Contact us and we’ll send the full list.

4. MD Order / Prescription

Use our blank fillable prescription form or your own. Either way, the order must be detailed — day vs. night wear, ready-to-wear vs. custom, and quantities.

If the prescription isn’t signed when you send it to us, we’ll follow up with the referring MD to obtain the signature.

5. Medicare Patients Only — Qualifying Diagnosis Note

Required: A note from the prescribing practitioner (MD, DO, NP, or PA) establishing the patient’s lymphedema or Mastectomy diagnosis. We cannot process Medicare orders without this.

• Can be an old note, office visit note, or hospital admission/discharge summary
• Must include a qualifying diagnosis (see below) — doesn’t need to be the main reason for the visit
• If you don’t have this on file, we’ll contact the referring MD to supply it
• Patients can also supply notes through MyChart or similar patient portals

Qualifying LYMPHEDEMA Diagnoses (ICD-10)

Qualifying Mastectomy Diagnoses (ICD-10)

A note on Medicare Advantage plans: Please don’t let network status dictate whether you send us Medicare Advantage patients. All MA plans except HMOs have out-of-network benefits, and we work with those routinely. We always verify coverage and let you and the patient know up front if costs differ meaningfully from in-network care.

How to Submit a Referral

Fax

866-984-3831

Questions?

Call us at 812-303-3831 — our staff can answer questions, help with garment selection, and walk you through the process.

What Happens After You Refer

1. Benefits Verification: We verify insurance and contact the patient to notify them of any out-of-pocket or upfront costs.
2. Patient Consents: We send the patient consents electronically (email or text).
3. Order Placement: Once the patient approves, we place the order and ship directly to the patient.
4. Communication: We notify you of any issues — insurance denials, difficulty reaching the patient, or backorder delays.

Turnaround Time: Approximately 10-14 business days. Delays can occur due to backordered products or difficulty reaching the patient for consents and payment.

Ready to Refer a Patient?

Get started by downloading the prescription form or sending us an email.