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/ / ( ) - ( ) - PATIENT INFORMATION / / , , REASON FOR VISIT LOCATIONS P (702) 676-2000 F (702) 676-2042 ( ) - ( ) - P (702) 676-2000 F (702) 676-2042 REFERRING PROVIDER/CASE MANAGER/ATTORNEY INFORMATION This transmission and the pages that follow are confidential and/or privileged. The information is intended to be for the use of Las Vegas Spine & Pain Center only. If you are not the intended recipient, please be aware that any disclosure, copying, distribution or use of the contents of this information is prohibited. If you have received this facsimile in error, please destroy all pages and notify the sender. The recipient of this information is bound to abide by the redisclosure language of Federal Law 42 CFR. Special Instructions / Requests: Consultation Only Consultation and Treatment Procedure Only or other STAT (First Available) Routine Providers: Date Name Phone Fax Name Phone DOB Alt Phone Primary Insurance Secondary Insurance Primary ID# Secondary ID# Address City, State, Zip HX / Diagnosis Independent medical exam Las Vegas Spine & Pain Center www.lvpainclinic.com 3270 North Buffalo Drive Las Vegas, NV 89129 ArlynValencia, MD David Tonkin, MD Brian Le, DO P (702) 676-2000 F (702) 676-2042 1641 E. Flamingo Rd., Ste 12 Las Vegas, NV 89119 PATIENT REFERRAL FORM Buffalo Location Flamingo Location Spring Valley Location 7150 W. Sunset Rd., Ste 202 Las Vegas, NV 89113 Insurance Lien/Personal Injury Worker’s Compensation Pain Management Neurology Addiction Infusion

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Page 1: PATIENT REFERRAL FORM

/ /

( ) - ( ) -

PATIENT INFORMATION

/ /

, ,

REASON FOR VISIT

LOCATIONS

P (702) 676-2000F (702) 676-2042

( ) - ( ) -

P (702) 676-2000F (702) 676-2042

REFERRING PROVIDER/CASE MANAGER/ATTORNEY INFORMATION

This transmission and the pages that follow are confidential and/or privileged. The information is intended to be for the use of Las Vegas Spine & Pain Center only. If you are not the intended recipient, please be aware that any disclosure, copying, distribution or use of the contents of this information is prohibited. If you have received this facsimile in error, please destroy all pages and notify the sender. The recipient of this information is bound to abide by the redisclosure language of Federal Law 42 CFR.

Special Instructions / Requests:

Consultation Only Consultation and Treatment Procedure Only or other

STAT (First Available) Routine

Providers:

Date

Name

Phone Fax

Name

Phone

DOB

Alt Phone

Primary Insurance Secondary Insurance

Primary ID# Secondary ID#

Address

City, State, Zip

HX / Diagnosis

Independent medical exam

Las Vegas Spine & Pain Centerwww.lvpainclinic.com

3270 North Buffalo DriveLas Vegas, NV 89129

Arlyn Valencia, MDDavid Tonkin, MDBrian Le, DO

P (702) 676-2000F (702) 676-2042

1641 E. Flamingo Rd., Ste 12 Las Vegas, NV 89119

PATIENT REFERRAL FORM

Buffalo Location Flamingo Location Spring Valley Location

7150 W. Sunset Rd., Ste 202 Las Vegas, NV 89113

Insurance Lien/Personal Injury Worker’s Compensation

Pain Management Neurology Addiction Infusion

Page 2: PATIENT REFERRAL FORM

ACCEPTED INSURANCE CARRIERS

LOCATIONS

Buffalo Location

Phone: (702) 676-2000Fax: (702) 676-2042

Las Vegas Spine & Pain Centerwww.lvpainclinic.com

3270 North Buffalo DriveLas Vegas, NV 89129

Phone: (702) 676-2000Fax: (702) 676-2042

Phone: (702) 676-2000Fax: (702) 676-2042

1641 E. Flamingo Rd, Ste 12 Las Vegas, NV 89119

7150 W. Sunset Rd, Ste 202 Las Vegas, NV 89113

Flamingo Location Spring Valley Location

• AARP• Aetna

o HMO/PPOo EPO/DOSo Managed Care

• Medicare (P3)• Alignment (P3)• Allwell (P3)• Ambetter• Anthem• Anthem BCBS Medicaid /

Amerigroup• Anthem Mediblue Plus (HMO)• Anthem Mediblue Coordination Plus

(HMO)• Assurant / Fortis• Beech Street• Blue Cross Blue Shield PPO/HMO• Caremore / Anthem Mediblue• Champ VA• Cigna• Compmed• Corvel• Coventry Health• Culinary• EBMS• Electrical Workers Health and

Welfare Trust• Fund• First Health / Coventry Network• Friday Insurance• Galaxy Health Network• Government Employee Health

Association (GEHA)• Great-West

• Healthsmart• Health Management Associates/

IMX• Health Net Federal Services• Health Plan of Nevada (HPN)• Hometown Health• Optum care• Human PPO• Interplan Health Group Network

(IHG)• Loomis Company• Mail Handlers Benefit Plan (MHBP)• Medicaid - Arizona• Medicaid - Nevada• Medicare• Meritain• Multiplan• Mutual of Omaha• One Health• Operating Engineer Trust Fund• Private Healthcare Systems

(PHCS)• Prominence Health Plan• Railroad Medicare• Secure Horizon - Medicare• Select Health• Senior Care Plus (P3)• Sierra Health & Life• Sierra Healthcare Options• Silver Summit• Smart Choice Medicaid• Southwest Administrators• Teachers Health Trust / Allegiance• Teamsters 631 - Local (JAS)• Tricare

• Tricare West VA• Tririga• Triwest• UFCW Local 711 (Multiplan)• United Health Care

(Commercial)• United Healthcare AARP Medical

Advantageo (HMO)o Plan 1 (HMO)o Premier (HMO)o Walgreens Plan 1 (HMO)o Choice (PPO)o Walgreens (PPO)

• United Healthcare Medicare Advantage

o Focus (HMO)o Assist (HMO-CNSP)o Patriot (PPO)

• United Healthcare Commercial• United Health Care Dual

Complete (Dual SNP)• United Medical Resources (UMR)• Universal Health Network /

Nevada Preferred Professionals• Victims of Crime Program• Well Health• Workman Compensation

o Treating Physician of Department of Industrial Relations (DIR)

o Treating Physician of Department of Labor

• Liens


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