{"id":781,"date":"2023-01-18T06:01:52","date_gmt":"2023-01-18T06:01:52","guid":{"rendered":"https:\/\/tricitypainassociates.com\/?page_id=781"},"modified":"2023-08-15T20:40:22","modified_gmt":"2023-08-15T20:40:22","slug":"physician-referral","status":"publish","type":"page","link":"https:\/\/tricitypainassociates.com\/physician-referral\/","title":{"rendered":"Physician Referral"},"content":{"rendered":"\n\n<h2>\n\t\tPhysician\n\t\tReferrals Form\n\t\t\t\t<\/h2>\t\n\t<div class=\"forminator-ui forminator-custom-form forminator-custom-form-681 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-681\" data-uid=\"663b0b567c228\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-681\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-681 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"681\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"663b0b567c228\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_663b0b567c228\" id=\"forminator-field-name-1_663b0b567c228-label\" class=\"forminator-label\">Patient Name: <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_663b0b567c228\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_663b0b567c228\" id=\"forminator-field-text-1_663b0b567c228-label\" class=\"forminator-label\">DOB <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_663b0b567c228\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_663b0b567c228\" id=\"forminator-field-date-1-picker_663b0b567c228-label\" class=\"forminator-label\">Date <span class=\"forminator-required\">*<\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_663b0b567c228\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1924\" data-end-year=\"2124\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_663b0b567c228\" id=\"forminator-field-phone-1_663b0b567c228-label\" class=\"forminator-label\">Patient Phone # <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_663b0b567c228\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_663b0b567c228\" id=\"forminator-field-text-2_663b0b567c228-label\" class=\"forminator-label\">Insurance <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_663b0b567c228\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_663b0b567c228\" id=\"forminator-field-text-3_663b0b567c228-label\" class=\"forminator-label\">Pain Diagnosis\/Pain Problem <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_663b0b567c228\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_663b0b567c228\" id=\"forminator-field-text-4_663b0b567c228-label\" class=\"forminator-label\">Reason for Referral <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_663b0b567c228\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_663b0b567c228\" id=\"forminator-field-text-5_663b0b567c228-label\" class=\"forminator-label\">Referring Physician <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_663b0b567c228\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_663b0b567c228\" id=\"forminator-field-text-6_663b0b567c228-label\" class=\"forminator-label\">Referring Physician Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_663b0b567c228\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_663b0b567c228\" id=\"forminator-field-phone-2_663b0b567c228-label\" class=\"forminator-label\">Referring Physician Phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_663b0b567c228\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_663b0b567c228\" id=\"forminator-field-phone-3_663b0b567c228-label\" class=\"forminator-label\">Fax<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_663b0b567c228\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"843927e4e4\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/781\" \/><input type=\"hidden\" name=\"form_id\" value=\"681\"><input type=\"hidden\" name=\"page_id\" value=\"781\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/tricitypainassociates.com\/physician-referral\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n\t\n<h2>FOR ALL HMO POLICIES, PLEASE FAX REFERRAL<\/h2>\n<h2>to <b>888-880-9323<\/b><\/h2>\n\n<h2>WE ACCEPT ALL ATTORNEY CASES WITH A VALID LOP<\/h2>\n\n<h2>WE ACCEPT ALL WORKERS COMPENSATION CASES<\/h2>\n\n<h2>All Major Insurances Accepted<\/h2>\n<p><strong><a href=\"tel:844-789-7246\">Call us<\/a><\/strong> for a complete list<\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>Physician Referrals Form 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 All Major Insurances Accepted Call us for a complete list<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_glsr_average":0,"_glsr_ranking":0,"_glsr_reviews":0,"footnotes":""},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages\/781"}],"collection":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/comments?post=781"}],"version-history":[{"count":10,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages\/781\/revisions"}],"predecessor-version":[{"id":1983,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages\/781\/revisions\/1983"}],"wp:attachment":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/media?parent=781"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}