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Practice Authority

Do you have full practice authority?YesNo

If “No,” do you have a collaborator?

Practice Information

Patient Population

Estimated number of patients treated monthly with chronic wounds:

Billing & Insurance

Do you accept Medicare Part B?YesNo

Do you work with any additional insurance plans?

Referral Network

Do you have a referral network for wound care?YesNo

If yes, please describe the types of providers you typically refer to

Disclaimer:

Dlin Medical strives to protect your health information in accordance with HIPAA regulations. We use your information solely for care coordination and do not share it without your consent, except as permitted by law.

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DLIN Medical Provider Sign-Up Checklist