Consultation Request for Physicians

Fax number: 304-598-2602

When faxing a new patient consultation request to the Pain Management Center, please include the following information:

• a completely filled out request form
• a copy of the report for the patient’s most recent MRI, CT scan, or x-rays pertaining to the reason for the request
• a letter of introduction and reason for the request (what you would like us to do, i.e., epidural, nerve root block, or specific request)
• a copy of the patient’s current insurance cards
• Please obtain authorization or pre-certification as required by insurance prior to sending consultation request.

Sending this information with the request will help us get the patient scheduled in a timely manner. ** We do not accept patients for the sole purpose of narcotic prescription.