Get the free 1773 Pain Management Referral Form 0711 - Aultman Hospital

ALTMAN CENTER FOR PAIN MANAGEMENT Phone (330) 4547237 * FAX (330) 4548682 Physician Direct Line (330) 5809132 Pain Management Physician Referral Form ...

How to fill out 1773 pain management referral

How to fill out 1773 pain management referral:

1. Begin by filling out the patient's personal information section, including their full name, date of birth, address, and contact information.
2. Indicate the patient's insurance information, including the name of their insurance provider and their insurance ID number.
3. Provide details about the referring physician, such as their name, contact information, and medical practice.
4. Specify the reason for the referral, including the patient's primary pain issue and any relevant medical history.
5. Include any supporting documentation or medical reports that may be necessary to support the referral.
6. Indicate the preferred date and time for the pain management appointment, if applicable.
7. Sign and date the referral form to validate the information provided.
8. Make a copy of the completed referral form for your records before submitting it to the appropriate pain management clinic or healthcare facility.

Who needs 1773 pain management referral?

1. Patients who are experiencing chronic or severe pain that requires specialized pain management services can benefit from a 1773 pain management referral.
2. Individuals who have been recently diagnosed with a painful condition or injury may also require a referral to a pain management specialist for further evaluation and treatment.
3. Patients who have not found relief from traditional pain management methods, such as over-the-counter medications, physical therapy, or alternative therapies, may also need a referral to explore more advanced pain management options.

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What is 1773 pain management referral?

1773 pain management referral is a form used to request a referral to pain management services.

Who is required to file 1773 pain management referral?

Healthcare providers are required to file 1773 pain management referral for their patients who require pain management services.

How to fill out 1773 pain management referral?

1773 pain management referral can be filled out by providing patient information, reason for referral, and any relevant medical history.

What is the purpose of 1773 pain management referral?

The purpose of 1773 pain management referral is to facilitate access to pain management services for patients in need.

What information must be reported on 1773 pain management referral?

Information such as patient demographics, medical history, current pain management regimen, and reason for referral must be reported on 1773 pain management referral.