Patient's Name

Address

City

State

Zip Code

Daytime Phone

Evening Phone

Email

Referring Physician

Referring Physician's Email

Referring Physician's Phone

Referring Physician's Fax

Primary Care Physician

Additional Information

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

1. Patient's insurance carrier information
   1. Primary Insurance
   2. Secondary Insurance
2. Is the patient Workman's Compensation?
3. 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.