Pain Injections by Referral from your physician
To schedule pain injections with Dr. Richard Alessi or Dr. James Derrisaw have your referring physician fax the following information to the attention of Acute Pain Scheduler at 970-472-9381:
PATIENT DEMOGRAPHICS:
- Name
- Address
- Phone Numbers
- Date of Birth
- Social Security Number
- Emergency Contact
- Name
- Address
- Phone Numbers
- Date of Birth
- Social Security Number
- Emergency Contact
INSURANCE CARRIER(S):
- Copy of Insurance Card(s)
- Name of Policy Holder, Member and Group Numbers, Provider Pre-certification Telephone Numbers
MEDICAL HISTORY: - Copy of Insurance Card(s)
- Name of Policy Holder, Member and Group Numbers, Provider Pre-certification Telephone Numbers
- Clinical Notes including Diagnosis (ICD-9 code) Reason for Referral (type of procedure recommended and what levels suggested for injection).
- Related Surgical Dictations
- Related MRI Reports
- Rx and Over the Counter Medications currently being taken
Comprehensive pain management services are provided by Dr George Girardi at his satellite office:
Front Range Pain Medicine
3744 South Timberline Road, Suite 102
Fort Collins, CO 80525
(970) 495-0506
http://www.frpmedicine.com