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Physician Referral Portal

Clinical Intake for Cranial Prosthesis (HCPCS A9282)

Section 1: Referring Provider Information

Clinic/Practice Name

Referring Physician Name

Point of Contact Email

Practice Phone Number

Section 2: Patient Information

Patient Full Name

Patient Phone Number

Patient Email

Diagnosis/Reason for Referral

Diagnosis/Reason for Referral

Section 3: Clinical Details & Documentation

ICD-10 Code

Urgency Level

Upload Prescription/Letter of Medical Necessity

If available. If not, RBS will coordinate with your office to obtain documentation after the initial consultation.

Section 4: Referral Action

How would you like us to proceed?

HIPAA & Privacy Statement

Privacy & Consent: By submitting this referral, I confirm that the patient has consented to have their contact and medical information shared with RBS Wig Studio for the purpose of a Cranial Prosthesis consultation. All data is handled in accordance with our privacy policy and will be used strictly for clinical coordination.

"Next Steps" Expectation

What happens next? *

We will contact the patient within 24–48 business hours.

We will verify their insurance benefits and schedule a consultation.

Your office will receive a confirmation once the patient has been seen.

Professional Signature

Professional Signature