Online Referring Provider Form

***Please Note: We do not accept Medicaid.***

In addition to completing this form, please upload files or fax all relevant medical records to (866) 702-0880.

Online Referring Provider Form

Patient Name

First

Last

Patient DOB*

Patient Phone Number(s)*

Patient Address*

Insurance Provider*

Policy Number*

Effective Date*

Preferred Physician*

Audra Eason, MD

Alexander Pisaturo, MD

Erin Morella, MD

Harrison Irons, MD

Other

Referral Type (please provide description in section below)*

Pain Management

Directed Procedure (IMAGING AND NOTES REQUIRED)

Upper Extremity Electromyogram (EMG)/Nerve Conduction Study (NCS)

Lower Extremity Electromyogram (EMG)/Nerve Conduction Study (NCS)

Description*

If pain management e.g. Low Back pain. If directed procedure e.g. epidural, steroid injection and specific body region.

Comments*

Detailed description regarding how we can assist your patient.

Location*

Please select2868 Acton Road, Birmingham, AL 35243727 Memorial Drive, Bessemer, AL 35022

Upload front and back of insurance card, demographic sheet, imaging, and clinic notes.

Please be sure insurance is active. We do not accept Medicaid, Work Comp, or self pay.

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Referring Provider

First

Last

Referring Provider NPI (if known)

Practice Name*

Specialty*

Contact Person

First

Last

Referring Practice Phone Number*

Referring Practice Fax Number*

EHR Direct Messaging Address*

Upload

Please type the characters*

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