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For Patients
Find a Doctor
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When To Seek Care
Bedsores
Burn Care
Diabetic Ulcers
Infected Wounds
Non-Healing Wounds
Venous Ulcers
Locations
Northeast
Connecticut
Delaware
Maine
Maryland
Massachusetts
New Hampshire
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New York
Pennsylvania
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Washington, DC
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Wound Care Intake
Step
1
of
8
- Your Information
0%
Find a Wound Doctor for Medicaid/Medicare
Tell us where you are and what insurance you have. WoundDock™ will review your information and help connect you with a wound-care provider in your area who accepts your insurance. WoundDock™ does not provide medical advice or emergency care. If you have a medical emergency, call 911 or seek emergency care.
Are you on Medicaid or Medicare or Both?
(Required)
Medicare
Medicaid
Both
What state are you located?
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Are you California or Texas?
(Required)
California
Texas
Other
Zip Code
(Required)
What is your Medi-Cal Plan?
LA Care
Health Net
Molina healthcare
Blue Shield Promise
Kaiser Permanente
IEHP
Partnership HealthPlan
CalOptima Health
CenCal Health
Health Plan of San Joaquin
Health Plan of San Mateo
Alameda Alliance
Other
I'm not sure
What type of Insurance do you have?
(Required)
Medicare
Texas Medicaid
Medicare + Texas Medicaid (Dual Eligible)
Other / I'm Not Sure
Select your Texas Medicaid plan
Molina Healthcare
Superior HealthPlan
UnitedHealthcare Community Plan
Wellpoint
Community Health Choice
Aetna Better Health
Blue Cross and Blue Shield of Texas
Cook Children's Health Plan
El Paso Health
Parkland Community Health Plan
RightCare from Scott & White
Texas Children's Health Plan
Traditional Medicaid / Fee-for-Service
Other
I'm not sure
Texas Medicaid Member ID
Wound Details
What kind of wound?
Diabetic foot wound
Pressure sore / bed sore
Leg Ulcer
Foot Ulcer
Sugical wound
Wound from an injury
Wound that won't heal
Other
I'm not sure
Where is the wound?
Foot
Toe
Ankle
Lower Leg
Knee
Thigh
Hip
Buttocks
Back
Abdomen
Arm
Hand
Other
I'm not sure
How long have you had this wound?
Less than 1 week
1-4 weeks
1-3 months
3-6 months
More than 6 months
More than 1 year
I'm not sure
Are you currently receiving wound care?
Yes
No
What help do you need?
Find a wound-care provider
Find a doctor who accepts my Medi-Cal plan
I need help getting an appointment
Find home wound-care services
Other
May a WoundDock team member contact you about your request for wound care assistance?
Yes
No
How Urgent?
ASAP
Within the next few days
Within the next week
Within the next few weeks
I'm just looking for information
If other (Let us know)
Is there anything else you'd like us to know about your wound or your situation?
Name
First
Last
Age
Phone
Email
Do you understand this form is not for medical emergencies?
(Required)
Yes
No
