SMPC Patient Referral

Fast Track Scheduling

SMPC Scheduling: 877-377-6227 Email: [email protected]

Additional med recs can be emailed to address above or faxed to 800-940-9601.

To print a copy for your records, fill out then hit File > Print, from the File Menu before you select 'Submit this Form'.

Please complete this form and click 'submit by email' above. Our scheduling department will call the patient to set up appointment and then call you to let you know appointment has been set. Red asterisk indicates required information. Thank you for the referral.

Date:*

Patient Name:*

Social Security No:

Date of Birth:

Home Phone:

Referring Physician:*

Phone No:*

Fax No:

Referring Office Contact:*

PCP:

PCP Phone No:

Face Sheet to be emailed separately

Insurance Info is included on this email

Marital Status:

Spouse's Name:

Street Address:*

City:*

State:*

ZIP Code:*

Employer:

Is this Work or Auto related?

Yes

If 'Yes' please provide the Claim No:

Date of Injury:

Insurance Carrier:

Adjuster Name:

Phone No:

Primary Insurance:

Contract No:

Insured Name:

Group No:

Employer:

Secondary Insurance:

Contract No:

Insured Name:

Group No:

Employer:

Reason for Referral:

Evaluate Only

Evaluate and Treat

Discogram

Medication Treatment Plan

IME/Disability Assessment

EMG

Osteopathic Manipulative Medicine

Physical Therapy

Behavioral Therapy

Post Surgical Complications

Return to Work Issues

Spine Center of Excellence (COE)

One Block/Epidural Only

Previous Studies/Treatments and Location and Date where Performed:

X-Ray

CT Scan

MRI

Discogram

Other

Date:

Where:

Pain Management (where and who):

If you are receiving transmission errors or have questions, please call
(616) 940-2662 ext. 1576 or (800) 281-3237 ext. 1576.
Form will not send if required areas are not all filled in.