Fillable PAIN MANAGEMENT & MVA REFERRAL

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PAIN MANAGEMENT & MVA REFERRAL

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  • 12 check-boxes
  • 18 other fields

Country of origin: OTHERS
File type: PDF

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Patient Name: Date of Referral:
Patient Phone Number: D.O.B
Diagnosis and Chief Complaint:
Insurance/Attorney: Authorization:
Group #: ID #: Date of Injury:
Referring Provider Name:
Referring Provider Phone: Fax:
Referring Provider Signature:
Contact Person: Phone:
Bring your MRI reports, medical records, insurance card/ID and co-pay. Se Habla Español
First M.I. Last
New Patient Consult
Pain Management
Medical Consultation
Insurance
Lien
Workers Compensation
Other: ______________
Medical Records Attached
REFERRED FOR:
David Lanzkowsky, M.D. | Mark Cirella, M.D. | Nianjun Tang, M.D. | Jerry Myers, D.O.
PAIN MANAGEMENT & MVA REFERRAL
E. Desert Inn Rd.
Maryland Pkwy.
S. Eastern Ave.
Burnham Ave.
Spencer St.
DECATUR LOCATION
4454 N. Decatur Blvd., Las Vegas, NV 89130
Next to Sonic
FLAMINGO LOCATION
2110 E. Flamingo Rd., Suite #330, Las Vegas, NV 89119
Near Desert Springs Hospital
N
Ann Rd
Rancho
Camino Al Norte Martin Luther King Blvd.
West Craig
Cheyenne Rd
Jones Blvd
N. Decatur Blvd
95
215
95
Rancho
Jones Blvd
Cheyenne Rd
Ann Rd
N. Decatur Blvd
15
DECATUR
LOCATION
Office: 702.839.1203 | Fax: 702.839.1301
FLAMINGO
LOCATION
E. Flamingo Rd.
E. Tropicana Ave.
click to sign
signature
click to edit
INSURANCE LIST
INSURANCE COMPANY CONTRACTED INSURANCE COMPANY CONTRACTED INSURANCE COMPANY CONTRACTED
AARP
In Network
GOLDEN RULE
In Network
RAILROAD MEDICARE
In Network
AETNA HEALTHCARE PPO & HMO
In Network
GREAT WEST
In Network
SIERRA CHOICE
In Network
ALLSTATE
In Network
HUMANA PPO/HUMANA CHOICE
In Network
SIERRA HEALTH & LIFE PPO
In Network
ANTHEM BC/BS PPO
Out of Network
JAS LOCAL 711
Out of Network
STATEFARM (AUTO)
In Network
ASSURANT
In Network
LOOMIS (CLARK COUNTY)
In Network
TEACHERS HEALTH TRUST
Out of Network
BEECHSTREET
Out of Network
MEDICAID
In Network
TEAMSTERS LOCAL 631
Out of Network
CARPENTERS H & W
Out of Network
MEDICARE
In Network
TEAMSTERS LOCAL 14/995
In Network
CIGNA PPO
In Network
MULTIPLAN
In Network
TRIWEST / TRICARE
In Network
CONVENTRY
In Network
NPP
In Network
UMR/LVMPD
Out of Network
DEPT OF LABOR
In Network
OPERATING ENGINEERS 12
Out of Network
UMR/VENETIAN/WYNN/MGM
In Network
FIREFIGHTERS H & W
Out of Network
OPERATING ENGINEERS 501
Out of Network
UNITED HEALTHCARE PPO
In Network
FIRST HEALTH
In Network
PAINTERS TRUST
In Network
USAA
In Network
GALAXY
In Network
PEBP
In Network
UNIVERSAL HEALTH
In Network
GEHA
Out of Network
PHCS
In Network
ZENITH AMERICAN
In Network
GHI/EMBLEM HEALTH
Out of Network
PLUMBERS & PIPEFITTERS 525
In Network
WE ALSO ACCEPT: MedPay, Automobile Accidents, Attorney Liens and Out of Network Insurance
DECATUR LOCATION
4454 N. Decatur Blvd.
Las Vegas, NV 89130
Next to Sonic
FLAMINGO LOCATION
2110 E. Flamingo Rd.
Suite 330
Las Vegas, NV 89119
PAIN MANAGEMENT
& ANESTHESIOLOGY
David Lanzkowsky, M.D.
Mark Cirella, M.D.
Jerry Myers, D.O.
SPORTS MEDICINE,
REHABILITATION &
PAIN MEDICINE
Nianjun Tang, M.D.
N
Rancho
DECATUR
LOCATION
W. Lone Mountain Rd.
W. Craig Rd.
W. Cheyenne Ave.
W. Lake Mead Blvd.
Las Vegas Blvd.
W. Washington Ave.
W. Charleston Blvd.
W. Sahara Ave.
W. Desert Inn Rd.
W. Flamingo Rd.
E. Flamingo Rd.
W. Tropicana Ave. E. Tropicana Ave.
Koval
S. Rainbow Blvd.N. Rainbow Blvd.
S. Jones Blvd.N. Jones Blvd.
S. Decatur Blvd.
N. Decatur
Blvd.
Martin
Luther King
N. Civic
Center Dr.
95
95
95
15
15
15
McCloud Dr.
S. Pecos Rd.
S. Eastern Ave.
Burnham Ave.
Maryland Pkwy.
Paradise Rd.
FLAMINGO
LOCATION
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PAIN MANAGEMENT & MVA REFERRAL

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Completed 7 May 2021

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