Get the free Pain Management Evaluation Referral Form - dhmc

Phone: (603) 650-6040 Fax: (603) 650-8199 Request for Evaluation Pain Management Center This referral form is for evaluation or consultation only. Please use the Procedure-only Appointment Request

How to fill out pain management evaluation referral

How to fill out a pain management evaluation referral:

1. Begin by entering the patient's personal information, including their full name, date of birth, address, phone number, and any relevant identification numbers such as a patient or insurance ID.
2. Next, provide the name and contact information of the referring physician or healthcare professional who is recommending the pain management evaluation.
3. Indicate the reason for the referral and provide a brief summary of the patient's medical history, including any relevant diagnoses, previous treatments, and medications they are currently taking.
4. Specify any specific concerns or goals for the pain management evaluation that should be addressed by the specialist.
5. If the patient has any known allergies or sensitivities, be sure to list them on the referral form to ensure appropriate precautions can be taken during the evaluation.
6. Ensure that all necessary supporting documentation is attached to the referral form, such as medical records, imaging reports, or previous test results, which can provide additional context for the specialist evaluating the patient.

Who needs a pain management evaluation referral:

1. Individuals who are experiencing chronic or persistent pain that has not responded well to previous treatments or interventions may require a pain management evaluation referral. This can include conditions such as arthritis, fibromyalgia, migraine headaches, back pain, or neuropathy.
2. Patients who require specialized procedures or interventions for pain relief, such as nerve blocks, epidural injections, or spinal cord stimulation, may need a referral to a pain management specialist who can assess their suitability for these treatments.
3. Individuals who have complex pain conditions that may require a multidisciplinary approach, involving input from various healthcare professionals, such as physical therapists, psychologists, or occupational therapists, may benefit from a pain management evaluation referral to coordinate their care effectively.

Remember, the specific criteria for needing a pain management evaluation referral can vary depending on the healthcare system, insurance coverage, and individual patient circumstances. It is always best to consult with a healthcare professional or your insurance provider for specific guidelines and requirements.

For pdfFiller’s FAQs

What is pain management evaluation referral?

Pain management evaluation referral is a process where a healthcare provider refers a patient to a specialist for the assessment and management of their pain.

Who is required to file pain management evaluation referral?

Any healthcare provider who believes a patient may benefit from further evaluation and treatment of their pain.

How to fill out pain management evaluation referral?

Fill out the referral form with the patient's information, medical history, and reason for the referral. Submit the form to the specialist or pain management clinic.

What is the purpose of pain management evaluation referral?

The purpose of a pain management evaluation referral is to ensure that patients receive appropriate care and treatment for their pain to improve their quality of life.

What information must be reported on pain management evaluation referral?

Patient's personal information, medical history, current symptoms, previous treatments, and any relevant diagnostic test results.

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