Physician Referrals Form Patient Name: *DOB *Date *Patient Phone # *Insurance *Pain Diagnosis/Pain Problem *Reason for Referral *Referring Physician *Referring Physician Address *Referring Physician Phone *FaxSubmit FOR ALL HMO POLICIES, PLEASE FAX REFERRAL to 888-880-9323 WE ACCEPT ALL ATTORNEY CASES WITH A VALID LOP WE ACCEPT ALL WORKERS COMPENSATION CASES Insurances Accepted: Aetna Amerigroup Blue Cross Blue Shield Cigna Humana Medicare Tricare Prime and Standard Triwest United Healthcare WellMed