Physician Referral Form
CALVON VOONG, M.D.
Diplomat, American Board of Physical Medicine and Rehabilitation
Diplomat, American Board of Pain Medicine
Diplomat, American Board of Electrodiagnostic Medicine
Ref. Physician:__________________________________________________
NPI #__________________________________________________________
Address:____________________________________ City:_____________________ State: ____ Zip:____________
Phone: _____________________________________
Fax: ____________________________________________
Fax: ____________________________________________ ***** REFERRING INFORMATIONS****
Referral for: (Mark One)
Consult and TX _____ Second Opinion Only _____ EMG/NCS_____
Diagnosis: ______________________________________________________________________________________
Please attach the following information:
• Recent notes describing the patient's pain problem and current treatments.
• X-ray / MRI / CT / EMG, etc, pertinent to pain problem.
• Copy of insurance card.
Patient Name: ________________________________________________ DOB: _____________________________
Address: ___________________________________ City: ____________________ State: ______ Zip: _________
Phone: ____________________________________
*****INSURANCE INFORMATION *****
Name of Insurance: __________________________________________________
Address: ___________________________________ City: _____________________ State: ______ Zip: __________
Subscriber ID: (claim# if work comp) ____________________________________________________
Name of Contact or Adjuster: _________________________________ Group#: _______ Date of Injury: ____________
Employer name: ____________________________________________________
Has authorization been obtained?Yes _____No _____ None required _____
Yes _____No _____ None required _____Records and authorization MUST be received prior to scheduling patients
Thank you for your referral.
15237 11th Street, Suite B
Victorville, CA 92395
(760) 243-3826 FAX (760) 962-8096
PM&R
EMG/NCS
PAIN MGT
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