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How to fill out the PHYSICIAN REFERRAL FORM Pain Management Group, LLC Ajit V ... online
Filling out the physician referral form is a crucial step in ensuring that patients receive the appropriate care and attention from the Pain Management Group, LLC. This guide will provide you with clear instructions on how to complete the form accurately and efficiently, allowing for a seamless online submission.
Follow the steps to complete the physician referral form online.
- Click the ‘Get Form’ button to obtain the form and open it in the designated online editor.
- Enter the patient's name in the appropriate fields, including first name, middle initial, and last name. Ensure the information is accurate as it will be used for identification.
- Fill in the date of birth (DOB) in the specified format to help verify the patient's identity.
- Provide the patient's contact numbers, including home, cell, and work phone numbers, as applicable. This information allows for better communication regarding the patient's care.
- Select the reason for referral from the provided options, including options such as consult and treat, consultation only, and other interventional procedures. Make sure to choose the reason that aligns with the patient's needs.
- Input the referring diagnosis in the designated space. This information will assist the receiving physician in understanding the patient's condition.
- Gather and attach pertinent medical records along with any other requested documents, like MRI or CT scan reports, as these details are essential for the assessment of the patient’s condition.
- If available, include a copy of the patient's current medical insurance card on both the front and back to facilitate billing and insurance processing.
- Indicate if the patient is on any blood thinners or aspirin. If the answer is yes and a procedure is scheduled, ensure to note that clearance is needed to discontinue the blood thinner five days before the procedure.
- Provide any additional comments or information that may assist the pain management team in their evaluation of the patient.
- Choose the preferred office location from the options given, ensuring that the selected facility is convenient for the patient.
- Fill in the referring physician's name and signature, along with the physician's contact number and fax number for follow-up purposes.
- After completing all fields accurately, review the form for any errors or omissions before proceeding to save, download, print, or share the form online.
Complete the physician referral form online today to ensure timely and effective pain management care.
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Fill PHYSICIAN REFERRAL FORM Pain Management Group, LLC Ajit V ...
Our physicians are fellowship-trained pain specialists who utilize a combination of interventional procedures and medication management. Ajit Pai, MD is a pain medicine physician in Mishawaka, IN and has over 45 years of experience in the medical field. Solution Chronic Pain Management Referral Form. Center for Pain Management. Physician Referral Form. Referral Form ; Referring Physician Name.
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