Fax the following Information to: 508-823-6127
insurance carrier information
i. Primary Insurance
ii. Secondary Insurance
- Is the
patient Workman's Compensation?
latest Medical history, MRI reports, X-Ray reports, EMG, and any
other pertinent information
of Personal Information
understand that Physicians 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 Physicians Pain
Management Center at 508-824-0035. 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.