Checklist for Referring Consultations to the
Pain Management Center
(please post for staff in your referring office)
PHONE: 415/885-PAIN (7246) • FAX: 415/885-3883
| Direct Referral Lines: | |
| For patients with last name beginning with A-K: | Mark Tucker 885-7533 |
| For patients with last name beginning with L-Z: | Louise Cartier 885-7351 |
2255 Post Street
San Francisco, CA 94143-1654
Campus Interoffice Box 1654
Call, mail, or fax the following information. We will contact the patient by phone to schedule their initial appointment and mail a referral packet that includes information about the Pain Management Center, directions, registration information, and a questionnaire that the patient needs to complete.
- Demographics
Patient's Name, Address, Phone Number
DOB, SSN, Insurance Information, UCSF or UCSF/Mount Zion Medical Record Number (if known)
Referring Physician Name, Address, Phone and Fax Number
Primary Care Physician Name, Address, Phone and Fax Number
(Most of the above can easily be accomplished by a copy or fax of a registration face sheet from your own clinic or center)
- Reason for consultation. Include records of previous medical evaluations, including operative reports, and psychiatric or psychological reports or tests that the patient may have had regarding their painful condition.
- Recent X-ray, imaging and special study reports (i.e.: nerve conduction studies, bone scans, etc.) that relate to their painful condition.
- Initial prior authorization for consultation and/or procedure (If the patient's insurance requires prior authorization, the referring physician's office must obtain authorization for our initial consultation and/or procedure. Insurance will not provide us authorization for
a patient we have yet to see. It is our responsibility to obtain any further authorizations.)
- Explain the referral to the patient so that they may understand what a multidisciplinary Pain Management Center program is about.