Physician Referral Form

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PHYSICIAN REFERRAL FORM
Date of request____________
Mercy Hospital Pain Ctr.
Mercy Harvard Pain Ctr.
1000 Mineral Pt Ave
902 Grant St
Janesville WI 53548
Harvard Il 60033
(608) 756-6049
(815) 943-8090
Fax (608) 756-6521
Fax (815) 943-2188
Patient Information
Requesting Provider Information
Name:___________________________________ Name:_______________________________
Address:_________________________________
City/State/Zip:____________________________
Address:____________________________
DOB:___________________________________
SS#:____________________________________
City/State/Zip:________________________
Phone-home:_____________________________
Phone-work:_____________________________
Phone:______________________________
Phone-cell:______________________________
Fax:________________________________
Insurance Provider:________________________
Subscriber/ID#:___________________________
Primary Medical Provider(if different from
above)
nd
2
Insurance:_____________________________ Name:_______________________________
Subscriber/ID#:___________________________
Phone:_______________________________
ALL WORKER’S COMP PATIENTS MUST HAVE:
Date of injury:_____________________________________
Claim number: _____________________________________
Name of WC insurance carrier: _____________________________________
Name of Caseworker: _____________________________________
Caseworker phone: _____________________________________
Services Requested:
____ Consult for Interventional Therapy
____ Consult for Medication Management
Please include recent office notes pertaining to current pain problems and MRI,CT of corresponding
area of spine. MUST include current (within 3 months) H&P and medications list.
Please Note:
*Medications are not routinely provided at initial consultation appointments.
** We do not provide detoxification or addiction management services.
Thank you. We will notify your patient when an appointment is scheduled, and will send a complete
report soon after patient is seen. We look forward to working with you…
The Mercy Pain Center Team

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