Wound Care Providers / Practices - Client Discovery Form

Client Discovery Form

Wound Care Providers / Practices

Purpose: This form collects provider, practice, wound care services, patient population, location, documentation, payer, compliance, and enrollment details needed to assess Medicare/Medicaid, Medicare Advantage, Medicaid MCO, commercial payer, DMEPOS, VA/TriWest, and wound care specialty network credentialing and enrollment requirements.

Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

Instructions: Complete every applicable field. Select only wound care services currently provided or planned. Upload supporting documents through the secure upload fields only. Do not email protected or sensitive documents.

1. Primary Client Contact & Organization Information

Primary Service Location *

Secondary Contact, if available

Practice / Organization Setting

2. Key Identifiers

State(s) of Licensure *

3. Scope of Work

Services Purchased / Requested *
Requested Payer Enrollment / Contracting * Select all applicable payer categories. When selected, provide the specific plan, program, or enrollment details below.
State(s) for Enrollment *

4. Key Project Information

5. Wound Care Provider Type / Specialty

Provider Type / Specialty
Practice Setting

6. Wound Care Services Offered

A. Types of Wounds Treated

B. Patient Populations Served

C. Levels of Wound Care Provided

D. Procedures & Clinical Services

E. Diagnostic Services

F. Provided Supplies & Durable Medical Equipment

7. Locations & Facility / Service Delivery Information

States Where Telehealth Is Provided

Add each service location and enter its hours.

8. Provider Billing & Coding Information

Common Wound Care Place of Service Codes Used

9. Provider Enrollment Roster

Complete one record per wound care provider, rendering provider, NP/PA, or supervised clinician requiring payer enrollment or credentialing.

10. Existing Provider Enrollment & Payer Participation

11. Ancillary Staff, Collaborative Providers & Referral Partners

12. Compliance & Clinical Protocols

Compliance / Clinical Documentation Available

13. Additional Notes / Special Considerations

14. Upload Supporting Documents

Documents containing protected health information, personally identifiable information, or other sensitive data must be uploaded only through the approved secure process and should not be sent through unsecured email.

Provider-Level Documents

Entity / Practice / Facility Documents

Wound Care / DME / Compliance Documents

15. Client Acknowledgements, Signatures & Certification

Privacy, Confidentiality, and Security of Credentialing Documents

TriumpHealth requires credentialing documents to be uploaded through the approved secure portal only. Do not transmit licenses, DEA certificates, IRS forms, insurance documents, clinical protocols, or sensitive information through unsecured email unless specifically instructed through an approved process.

Credentialing, Site, and Payer Requirements

The client acknowledges that wound care payer participation may depend on provider licensure, service location, place of service, billing structure, DMEPOS requirements, supervision rules, payer site requirements, and clinical documentation standards. Failure to disclose mobile service locations, supply billing, DMEPOS activity, provider supervision arrangements, or payer-specific limitations may cause delays, denials, or enrollment rejections.

Completion and Reimbursement Disclaimer

This Discovery Form is used to determine credentialing, enrollment, contracting, billing setup review, and compliance requirements. Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

Scope of Work Precedence

In the event of any conflict, inconsistency, or discrepancy between the Scope of Work set forth in the executed Service Agreement and any project-scope information provided in the Client Intake Form, the terms of the executed Service Agreement shall control and be deemed final and binding.

I certify that the information provided in this form is true, complete, and accurate to the best of my knowledge. I authorize use of this information for payer enrollment, credentialing, contracting, billing setup review, and compliance assessment.
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