Physician Office Referral Order Pain Management Center

PLACE LABEL HERE

PHYSICIAN OFFICE REFERRAL ORDER

Pain Management Center

PLEASE COMPLETE:

1.  Do you want our physicians to take over complete care for pain management, including controlled substance medication? q Yes *** If No – Is this a limited consult for a procedure recommendation? q Yes

2.  Has patient been to another facility/physician for pain management? q Yes q No

If yes, When? ______Facility/Physician Name:______Phone # ______

3.  Diagnosis: ______ICD9 Code:______

PATIENT INFORMATION: q See Attached (you may include a demographic page, but please write name and DOB)

______

Legal Name: Last First DOB

______

Street Address City/Zip County

______

Home # Cell # E-mail

PAYMENT INFORMATION: (√ box that applies & include card copy)

q Commercial Insurance q Medicare q Medicare Replacement / Advantage Plans q Medicaid

Primary Insurance______q HMO/ POS q PPO Is PCP referral required? q Yes q No

Secondary Insurance______q HMO/ POS q PPO Is PCP referral required? q Yes q No

q Tricare: Please provide authorization if required by patients plan

q Self Pay: $150 due at initial visit & $50 for follow-up office visits

q Work Comp: Please provide an approval notice from the work comp agency:

Include the claim #, billing address, adjusters name and phone #, and date of injury

THE FOLLOWING DOCUMENTS ARE REQUIRED TO REVIEW THE REFERRAL – FAX TO 678.312.5215

a. Physician Office Referral Order Form (including insurance information)

b. Office notes 6 months from last visit – including medication regimen

c. Radiology reports, nerve conduction studies/EMG, other reports pertaining to diagnosis

d. Previous Pain Management records and/or other specialists records pertaining to patients condition

REFERRING PHYSICIAN: Signature:____________Referral Date: ______

Contact Person: ______Phone # ______Fax # ______

PCP Name & Phone # ______

***We will attempt to schedule your patient within 10 business days after receiving all required documentation or notify your office by fax if we are unable to schedule your patient***

OFFICE USE ONLY Scheduled with: q Reisman q Smith q Alvear q Hodgson q ______

Appointment: ______Arrival time: ______Rescheduled:______Arrival time:______

New Pt Packet: q Mailed q Faxed q Emailed q Picked- Up Date/Initial: ______

Reminder Call: q Confirmed q No Answer q Left Message Date/Initial: ______

*1-26095* FORM 1-26095 REV. 01/2014 Page 1 of 1