Referral Information

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.

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.

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.

We would be happy to answer any questions you have by contacting our staff.

 





Patient’s Name (required)

Email (required)

Daytime Phone

Evening Phone

Referral Physician Name

Referral Physician Phone

Referral Physician Fax

Primary Physician Name

Additional Information

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You may fax the following information to (401) 729-6019:

  • Patient’s insurance carrier information
  • Primary insurance
  • Secondary insurance
  • Is the patient Workman’s Compensation?
  • Patient’s latest Medical history, MRI reports, X-Ray reports, EMG, and any other pertinent information.

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.

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.

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