Get the free 1196 Chronic Pain Referral Form rev May 1315v4

Partners Against Pain Integrated Pain Services Chronic Pain Clinic REQUEST FOR CONSULTATION Page 1 of 4 Patient Identification Referral by Physician / Nurse Practitioner Only The goal of the Chronic

How to fill out 1196 chronic pain referral

How to fill out 1196 chronic pain referral:

1. Start by entering the patient's personal information on the form, such as their full name, address, and contact details.
2. Provide the patient's date of birth and social security number, if applicable.
3. Indicate the reason for the referral as "chronic pain" in the appropriate section of the form.
4. Specify the duration of the pain and its location, if required.
5. Include any relevant medical history of the patient that may contribute to the chronic pain, such as previous injuries or existing medical conditions.
6. Provide a description of the pain, including its severity and any associated symptoms.
7. If the patient has previously undergone any treatments or medications for the chronic pain, mention them in the referral form.
8. If the referral is being made by a healthcare provider, include their name, contact information, and their specialty.
9. Finally, make sure to sign and date the referral form to validate its authenticity.

Who needs 1196 chronic pain referral:

1. Patients who have been experiencing chronic pain for an extended period.
2. Individuals seeking specialized medical care or treatment for chronic pain.
3. Healthcare providers or clinicians referring patients to pain management specialists or specialized clinics for further evaluation and intervention.

For pdfFiller’s FAQs

What is 1196 chronic pain referral?

1196 chronic pain referral is a form used to refer patients with chronic pain to specialized healthcare providers for evaluation and treatment.

Who is required to file 1196 chronic pain referral?

Healthcare providers, such as physicians or pain management specialists, are required to file 1196 chronic pain referrals.

How to fill out 1196 chronic pain referral?

1196 chronic pain referral should be filled out with patient information, medical history, pain assessment, treatment plan, and provider details.

What is the purpose of 1196 chronic pain referral?

The purpose of 1196 chronic pain referral is to ensure patients with chronic pain receive appropriate care from specialized healthcare providers.

What information must be reported on 1196 chronic pain referral?

Information such as patient demographics, medical history, pain assessment, treatment goals, provider details, and referral reason must be reported on 1196 chronic pain referral.

How can I send 1196 chronic pain referral for eSignature?

When you're ready to share your 1196 chronic pain referral, you can swiftly email it to others and receive the eSigned document back. You may send your PDF through email, fax, text message, or USPS mail, or you can notarize it online. All of this may be done without ever leaving your account.

How do I edit 1196 chronic pain referral straight from my smartphone?

The best way to make changes to documents on a mobile device is to use pdfFiller's apps for iOS and Android. You may get them from the Apple Store and Google Play. Learn more about the apps here. To start editing 1196 chronic pain referral, you need to install and log in to the app.

How do I fill out the 1196 chronic pain referral form on my smartphone?

The pdfFiller mobile app makes it simple to design and fill out legal paperwork. Complete and sign 1196 chronic pain referral and other papers using the app. Visit pdfFiller's website to learn more about the PDF editor's features.