Get Healthspan Pain Management Form

Filling out the Healthspan Pain Management Form online is a straightforward process that ensures your pain management requests are processed efficiently. This guide will walk you through each section of the form, providing clear instructions to help you complete it accurately.

Follow the steps to fill out the Healthspan Pain Management Form online.

1. Press the ‘Get Form’ button to access the Pain Management Fax Authorization Form and open it in your preferred editor.
2. Begin by entering the date of your request in the designated field.
3. Fill in the member's name and member ID to identify the individual for whom the form is being submitted.
4. Indicate whether the service is related to a motor vehicle accident or worker’s compensation by checking the appropriate box.
5. Provide the physician’s full name and tax identification number (TIN) in the relevant fields.
6. Complete the office location and include contact details such as the contact person's name, phone number, and fax number.
7. In the facility information section, enter the name of the facility, its TIN, and the date of service along with the location of service.
8. For the clinical information, select whether the procedure is outpatient or in-office, and describe the procedure clearly.
9. List any and all procedure (CPT) codes related to the procedure you are requesting.
10. Provide a detailed diagnosis description and relevant diagnosis codes.
11. Specify the reason for the procedure and select the applicable area such as diagnostic, cervical, therapeutic, thoracic, lumbar, sacral, or other.
12. Indicate the level of injection or muscle group for trigger point injections.
13. List the signs and symptoms relevant to the request.
14. Detail any conservative treatments that have been previously tried for the primary diagnosis.
15. Record the history of injections received in the past 12 months by filling out the date, type of injection, level, percentage of relief, and duration of relief.
16. After completing all sections, review the form for accuracy and save your changes. You may then download, print, or share the filled form as needed.

Complete your Healthspan Pain Management Form online today for timely processing.