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

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

Detailed description regarding how we can assist your patient.

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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