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*

Pain Management

Directed Procedure

Upper Extremity EMG/NCS

Lower Extremity EMG/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

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*

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