Forms

Referral Mechanisms:

• Phone us at 1.800.777.3574
• Referral form for any pharmacy or ancillary service. download
• Referral form for pharmacy services. download
• Referral form for medical equipment and supplies, or health services. download
• Intervention RX^TM download
• Physical Medicine Referral form. download
• Long-Term Care Referral form. download
• Long-Term Care Purchase Order. download

Do you need a quote?

• We will be happy to provide a quote so you can make an informed decision for a future referral. Please include all necessary specifications in your e-mail, including how you would like us to contact you with pricing. 

Ohio BWC C-9 Form:

• Ohio BWC C-9 Form. download

HIPAA Forms:

Progressive Medical is HIPAA Compliant. The PDF documents below are official HIPAA Forms. Click on the appropriate document for a printable form:

• Authorization for Use and Disclosure of PHI. download
• Revocation of Authorization. download
• Request for Accounting of Disclosures. download
• Request for Confidential Communication. download
• Request for Restriction of PHI. download
• Request to Amend Records. download
• Permission to Speak With Form. download

If you need to verify employment of a Progressive Medical associate, you may go to www.verifyjobhistory.com and use company code 1614.