Forms

 

Forms

see Our group is eager to work in conjunction with referral physicians and primary care doctors. We highly encourage direct contact to any of our Pain physicians and physician assistants to discuss any issue they may have.

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watch We also appreciate all pertinent medical information about the patient you would like to refer. All this data will be reviewed prior to scheduling an appointment.

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agencias matrimoniales serias gratis The reason for this pre-evaluation is to ensure to both patient and colleagues that the patient is a good candidate for the treatment plan we can offer.

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opzioni digitali da 10 We would be happy to answer any questions you have by contacting our staff.

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site de rencontre jvc You may fax the following information to (401) 729-6019:
1) Patient’s insurance carrier information
2) Primary insurance
3) Secondary insurance
4) Is the patient Workman’s Compensation?
5) Patient’s latest Medical history, MRI reports, X-Ray reports, EMG, and any other pertinent information.

source Security of Personal Information
You should understand that the Pain Management Center cannot absolutely guarantee the confidentiality or security of information your provide in the referral form.

go site We will use your referral form to begin arranging for care where appropriate and necessary. The information you provide will be kept private in accordance with our confidentiality policies, and will be seen by a limited number of authorized individuals as necessary. If you need to change this information, please contact our Pain Management Center at (401) 729-4985. We may contact you if we need to verify or obtain further information. You should understand that this referral form does not establish a doctor-patient relationship. You may become a patient if you come to our center for treatment. At that point, this form will become part of your medical record.