REFERRAL FORM 1ST AVAILABLE REVELIS - Tulsa Pain 2025

1. Click ‘Get Form’ to open the REFERRAL FORM in our editor.
2. Begin by selecting the appropriate service requested, such as Injection Therapy or Evaluation, and provide any additional details in the space provided.
3. Fill in the patient's full name and contact numbers for home, work, and cell. Ensure accuracy for effective communication.
4. Complete the address and date of birth fields, along with the Social Security number if required.
5. Enter the referring physician's name and phone number, followed by their address and fax number.
6. Document the diagnosis and date of injury clearly to assist in processing.
7. Provide insurance information, including primary and secondary details, claims address, phone number, contact person, case/ID number, and group number.
8. If available, fax copies of insurance cards along with this form. Also, ensure that medical records are sent with all diagnostic reports.
9. Finally, specify the desired appointment date and time before submitting your completed form.

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