For Our Providers

Note: Incomplete referrals may delay patient scheduling and surgery authorization. Please ensure records are legible, recent and complete. SEND RECORDS WITH YOUR REFERRAL TO AVOID DELAYS.

Referral Form For Providers

Records to Send with a Referral

  • Patient demographics: contact information, date of birth, address, phone number
  • Insurance details: plan information and referral or authorization if required
  • Referral reason
  • Last provider’s visit note
  • Most recent imaging report with date and location

Additional Records by Procedure

Spinal cord stimulator

  • Trial procedure note
  • Provider visit note after trial
  • Psychological evaluation

Pain Pump Replacement

  • Trial procedure note
  • Provider visit note after trial
  • Psychological evaluation

SI Joint Fusion

  • SI injection procedure notes
  • Provider visit note after injections