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  • Referral Form5

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    fuzuku
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    A referral form for the Integrative Pain Center of Arizona provides sections for a referring doctor to fill out patient and insurance information, select preferred providers, and request specific services including physician consultation, follow up visits, psychology evaluation and testing, and occupational medicine evaluations. The form requests faxing of patient demographics, recent office notes, imaging reports, and prior authorization if required by the patient's insurance.

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    A referral form for the Integrative Pain Center of Arizona provides sections for a referring doctor to fill out patient and insurance information, select preferred providers, and request specific services including physician consultation, follow up visits, psychology evaluation and testing, and occupational medicine evaluations. The form requests faxing of patient demographics, recent office notes, imaging reports, and prior authorization if required by the patient's insurance.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    10 views1 page

    Referral Form5

    Uploaded by

    fuzuku
    A referral form for the Integrative Pain Center of Arizona provides sections for a referring doctor to fill out patient and insurance information, select preferred providers, and request specific services including physician consultation, follow up visits, psychology evaluation and testing, and occupational medicine evaluations. The form requests faxing of patient demographics, recent office notes, imaging reports, and prior authorization if required by the patient's insurance.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    REFERRAL FORM

    INTEGRATIVE PAIN CENTER OF ARIZONA


    3945 E. PARADISE FALLS DR., SUITE 105
    TUCSON, AZ 85712
    Tel: (520)-797-7246 Fax: (520)-795-4249
    www.ipcaz.org

    Thank you for referring to IPCA!!!

    Fax to: New Patient Scheduler 795-4249


    Date:________________

    Patient
    Name:____________________________DOB:________Phone:____________________

    Diagnosis:_______________________________________________________________

    Insurance: Primary________________________ID#_____________GRP#___________

    Secondary______________________ID#_____________GRP#___________

    Insurance Authorization:____________________________________________________

    Referring Doctor Signature:________________________________Phone:____________

    Referring Office Fax:____________________ Office Contact _____________________

    Physician Consultation (99243-45) and three office follow up visits (99211-99215)

    If you have a preference, select an IPCA provider:


    □ Dr. Mitchell Halter □ Dr. Bennet Davis

    Dr. Cela Archambault, psychology, evaluation and testing (CPT codes are insurance specific;
    please call 797-7246, ext 114)

    Dr. Randy SooHoo, Occupational Medicine & Disability Evaluation


    Disability Evaluation (99456)
    Work Status Evaluation (99456)
    Functional Capacity Evaluation (97750)

    PLEASE FAX THE FOLLOWING:


    Patient Demographics
    Recent Office Notes
    Recent Imaging Reports (x-ray, MRI, CT scan)
    Prior Authorization (If required by patient’s insurance)

    We will call your patient within 24 hours of receiving your fax AND the supporting documents
    11/09

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