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 NameFirstLastPatient DOB*Patient Phone Number(s)*Patient Address*Insurance Provider*Policy Number*Effective Date*Preferred Physician*Audra Eason, MDAlexander Pisaturo, MDErin Morella, MDHarrison Irons, MDOtherReferral Type (please provide description in section below)*Pain ManagementDirected 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 35022Upload 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. Referring ProviderFirstLastReferring Provider NPI (if known)Practice Name*Specialty*Contact PersonFirstLastReferring Practice Phone Number*Referring Practice Fax Number*EHR Direct Messaging Address*UploadPlease type the characters*This helps us prevent spam, thank you.SendThis field should be left blank