Forms

CHICAGO PAIN CLINICS L.L.C

Phone# 708-344-1234

FAX # 800-525-1686

Dear Physician,

The below links are forms

which can

be

downloaded.

These

documents can either

be

printed

or edited

and returned to us by

F

ax

to

773-894-

0320.

We recognize

these forms do take

a few

minutes to complete and we

recognize your

time is

valuable.

However, this information

helps

us care for your patient. Please

send

any

additional

reports such

as EMG/NCS or

imaging

studies to

our above

fax

#

so that are

best

equipped

to care for

your patients.

We are able to initiate accepting patient by

having three below document in one package

fax to 773-894-0320:

1)

Referral

form( filled by

referral

physician).

2) Imaging study report.( if it was done).

3) Pain question

n

a

ire

form ( filled by patient).

For i

nitiating

referral

Please ask pt to

complete

pain question

ire

an

d attached with

imaging study report

and

r

efferral form and fax to above Fax

number.

Thank you for

involving us in the

care of

your

patient.

Physician's Referral Forms below:

Out-patient Referral form

Dear Patient,

In order for Chicago pain clinic to best care

for your

needs, the

information

on these

forms are

extremely

helpful in our ability to

diagnose and treat your

condition. The

below forms can be

downloaded and

completed by hand and

returned to us by

fax

to

773-

894-0320. Please return

this

three

forms and

official

result

of any Image

study

(MRI, CT Scan, X-Ray and

etc..) in

order

for

us

to contact you for an

appointment

date.

Patient 's Pain Questionnaire Form
below:

pain Questionnaire form

Notice of Privacy Practices (Please read,
then print and sign last page):

HIPAA Form

Demography form:

Demography form