Refer a Patient

Please complete the form below or call a specialist on our team.

1-855-334-5836

Email:
[email protected]

Fax Number:

First Name:

Last Name:

* required

Insurance provider information

Patient information

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip Code:

* Phone Number:

* Email:

* Date of Birth:

Referring Agent Information

* First Name:

* Last Name:

* Phone Number:

* Email Address:

* Company Name:

* Relationship to Patient:

* Upload documents. (accepted file types are: pdf and jpg)

Please Note:
Fax any related documents to 1-855-821-5520 noting the reference number that will be displayed after you submit the referral form.

The above-named patient gave me consent to refer him/her to Liberator Medical^™ and to authorize Liberator Medical^™ to contact the patient by email, text, phone, and mail. I also read and agree, on the patient’s behalf, to Liberator Medical’s^™ privacy policy.

Practice & agency coordination team contact

Physician line -David Velez

1.800.550.3224

[email protected]

Downloadable forms:

Assignment of benefits (AOB)

Detailed written orders (DWO)

Practice referral highlights

Reduction of calls and faxes

E-Prescribing

Dedicated coordinator

Home health agency referral program highlights

Continuity of care for patients once discharged

Competitive business-to-business prices

Free samples for agency or patient to identify high quality, cost-effective products

Reminder call/email/fax to order patient supplies to help ensure they don’t run out

Liberator Medical has earned The Joint Commission’s Gold Seal of Approval and has an A+ rating with the Better Business Bureau.

The Joint Commission's Gold Seal of Approval and has an A+ rating with the Better Business Bureau.

MAGIC³ Go® Female Hydrophilic Catheter

Ostomy Issues: Skin Irritation

We will navigate your insurance so you don’t have to

Refer a Patient

1-855-334-5836

Fax:
1-888-205-1558

Email:
[email protected]

Insurance provider information

Patient information

Referring Agent Information

Practice & agency coordination team contact

Downloadable forms:

Practice referral highlights

Home health agency referral program highlights

MAGIC³ Go® Female Hydrophilic Catheter

Ostomy Issues: Skin Irritation

We will navigate your insurance so you don’t have to

Refer a Patient

1-855-334-5836

Fax: 1-888-205-1558

Email: [email protected]

Insurance provider information

Patient information

Referring Agent Information

Practice & agency coordination team contact

Downloadable forms:

Practice referral highlights

Home health agency referral program highlights

Fax:
1-888-205-1558

Email:
[email protected]