Physician Referral Form (For HMO’s please fax the paper referral to 480-344-1626)

Please complete and submit the referral form below or you can download, print and complete a referral form here.


Please select a location: 6309 E. Baywood Ave., Mesa, AZ 85206
 
First Name Last Name DOB Phone
Primary Insurance Secondary Insurance
Referring Diagnosis (es)

PLEASE INCLUDE: ALL REFERRAL / AUTHORIZATIONS AS NEEDED, COPY OF INSURANCE CARDS, CHART NOTES, RADIOLOGY REPORT(S) AND MEDICATION LIST.
 
Referring Physician
Phone Fax

BOARD CERTIFIED PHYSICIANS
 
Medical Treatment
Schedule Exam with:
 
First Available Eric Boyd, MD Richard Ruskin, MD Karl S. Hurst-Wicker, MD    
 
Evaluate and Treat (please check all that apply):
 
Neck Headache Medication Management  
Shoulder Hip Other  
Lower Back Knee  
Upper Back Ankle    
 
RX EMG/NCS
 
Reason for Test (please check all that apply):
 
Numbness/Tingling Arm Right Left Bilateral  
Weakness Leg Pain Upper Limb Lower Limb    
 
Fax written report to
Rule Out
Carpal Tunnel Syndrome Lumbosacral Radiculopathy
Ulnar Neuropathy Lumbosacral Plexopathy
Cervical Radiculopathy Peripheral Neuropathy
Brachial Plexopathy  
Call verbal
Preliminary report to
 
 
Physician’s Name Date
 
 
 
 

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