For Referring Physicians

Screen-Shot-2016-02-17-at-9.37.13-AM-300x205

We welcome the opportunity to partner with you in caring for your patients.

The decision to refer a patient to Commonwealth Spine and Pain Specialists should be easy. We also want the referral process to be easy for you, your staff, and your patients. When you refer to us, we will keep you informed of your patients’ progress to ensure a smooth continuation of care. In order to refer a new patient, please fill out the form below.

PLEASE REMIND PATIENT:

Patient MUST have a driver accompany them for the procedure.
Patient cannot be on blood-thinner medication and have the procedure same day (Coumadin, Plavix, etc.).
Patient cannot be on antibiotics for an active infection.
Certain insurances companies REQUIRE prior authorizations (Coventry, Humana, Medicare, Anthem HK Plus, etc.)

PLEASE COMPLETE THE FORM BELOW AND FAX TO (804) 288-4556. PLEASE REMIND PATIENT TO HAVE PROPER INSURANCE REFERRAL FOR THEIR APPOINTMENT.

Please send only the following:

referral form
last three office visits
any advanced imaging
patient’s demographics

Patient Referral

Referring Physician Name*
Practice Name*
Practice Address*
Street Address City State ZIP Code
Patient Name*
First Last
SSN*
Address
Street Address City State ZIP Code
Patient D.O.B.
MM slash DD slash YYYY
Phone
Insurance
Exam/Procedure Requested*
- Epidural Steroid Injection
- Transforaminal Injection
- Trigger Point Injection
- Facet Joint Injection
- Sacroiliac Joint Injection
- Consultation
- Eval & Treat
- Other
Please provide details necessary for exam/procedure*
(i.e. - level/location of injection)
Please verify your submission