CPM Centres for Pain Management Central Intake Department Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7 P: 905 288-1022 TF: 800 265-3429 Ext 1022 F: 905 858-0111 TFF: 877 883-3301 CPM Patient Referral Checklist To optimize our central intake and referral process please include ALL required information outlined in the checklist: ❑ Fully completed CPM Central Intake Patient Referral Form ❑ Request for Telephone Consultation (if applicable) ❑ Diagnostic Imaging - MRI and CT Reports of the affected areas no older than 5 years ❑ Medical history and list of medications ❑ Relevant consultation, treatments and surgical notes ❑ History of drug/alcohol abuse or addiction ❑ Patient demographics ❑ MD demographic and billing number (see note below) ❑ Other: ________________________________________________________________ IMPORTANT: Did you know that some of our Centres for Pain Management MD’s have their Focused Based Practice Designation? This means referring physicians who belong to a FHT, FHO, FHN and FHG practice model WILL NOT be negated. Please contact our Central Intake staff if you have any questions or concerns.
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CPM Patient Referral Checklist - Health Services for ... · Thank you for referring your patient with chronic pain to one of our CPM centres for assessment and/or treatment. I would
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CPM Centres for Pain Management
Central Intake Department Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7
Dear Primary Care Practitioner, Thank you for referring your patient with chronic pain to one of our CPM centres for assessment and/or treatment. I would like to highlight some of the benefits our centres can offer you and your patients.
Centralized Intake Process: We have a Centralized Intake Process to standardize screening of each referral. This process ensures that all required information for the consultation has been received. The efficiency of this process helps us to see your patient on a timelier basis. Timely Assessment of Sub-Acute Pain: The earlier a patient with pain is treated, the more likely a successful outcome will occur. Painful conditions treated within the first 3-6 months using a multimodal approach have the highest chance of full recovery. Patients with pain for more than 18 months can typically expect some reduction in pain and improvement in the quality of life, but it is unlikely their condition will be resolved. We therefore try to prioritize patients with sub-acute pain. Timely Access to Multidisciplinary Treatments: Our goal is to provide comprehensive, caring, chronic pain management whenever possible. Many components of multidisciplinary care are not funded by OHIP. CPM will provide the Stanford-based, 6-week, Chronic Pain Self-Management Program to all CPM patients at no charge. For patients with supplemental health coverage, we can provide other elements of comprehensive care: exercise, massage, cognitive-behavioural therapy, and nutrition counselling etc. For patients without coverage we may refer to community and online resources. New patient referrals to CPM will be prioritized based on:
a. The need for a one-time consultation vs. a period of active care
b. Duration of the painful condition
c. Extent of 3rd
party coverage Telephone Consultation: We offer the option of a brief telephone consultation, to better support primary care practitioners (PCPs) whose patients might have to wait to be seen at our centres. This is now a funded service in the OHIP Schedule of Benefits – both for the referring and consulting physician. It is suitable for a patient with chronic pain, where there are a small number of specific questions to help the PCP continue ongoing treatment. A specific 1-page referral form can be sent at your request. You can also request telephone consultation patients currently under the care of a CPM physician.
We continually strive to improve our service offerings to referring physicians and patients with pain. Please contact our central intake staff if you have any questions or concerns about referring your patients to CPM.
CPM Centres for Pain Management
Central Intake Referral Form
Patient email address if available:
Please circle applicable practice model:
FHT FHG FHN FHO Other
Is this a WSIB Claim? Y N Claim #
MVA Claim? Y N
Is patient receiving Ontario Disability Benefits? Y N
Is patient receiving Long-Term Disability Benefits? Y N
Are you this patient’s family physician? Y N
Patient Medical Profile - Please indicate the clinic you wish your patient to be seen in:
Toronto Mississauga Brampton Scarborough
Oakville Oshawa London Ottawa Hamilton
Specific CPM MD:
Medication advice only? Y N
Request for 10 min MD phone conversation? Y N
If yes, please complete attached Request for Telephone Consultation form
Primary Diagnosis:
Length of pain complaint:
Secondary Diagnosis:
History of alcohol and drug addiction? Y N
Patient’s Past Medical Treatment Profile - Please attach a full list of current medications Has the patient received any of the treatments listed below?
1. A maximum of one K730 service is eligible for payment per patient per day.
2. This service is only eligible for payment for a physician to physician telephone consultation service:
a. that includes a minimum of 10 minutes of patient-related discussion for any given patient, and;
b. where the referring physician and consultant physician are physically present in Ontario at the
time of the service.
Medical record requirements:
Physician to physician telephone consultation is only eligible for payment where the following elements
are included in the medical record for a physician who submits a claim for the service:
1. Patient’s name and health number; 2. Start and stop times of the discussion; 3. Name of the referring and consultant physicians; 4. Reason for the consultation, and; 5. The opinion and recommendations of the consultant physician.
Claims submission instructions:
K731 is only eligible for payment if the consultant physician includes the referring physician’s billing
number with the claim.
Request for Telephone Consultation – Pain Management
Physician Name: OHIP Billing No.
Back Line Telephone No. Best time on Tuesday to call:
Patient Name:
DOB: HCN:
Brief history of the pain problem and current treatments (attach additional pages if required):
Specific questions to discuss:
Date of discussion: Start – Stop times:
Record of issues discussed / advice given:
Billing: - Referring MD:
K730 Consulting MD: K731 Diagnostic Code:
AIM Health Group – Health and Wellness Centres
Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7 P: 905 858-1368 F: 905 858-1399
See page 7 of the referral form for a list of our locations or visit www.aimhealthgroup.com.
We have Rehabilitation Services!
The AIM Health Group division of Viable Healthworks offers complementary and alternative
medicine and rehabilitation services at most Centres for Pain Management locations including:
Acupuncture Custom Bracing and Supports Chiropractic Care Kinesiology Massage Therapy Naturopathic Medicine Orthotics and Orthopaedic Shoes Personal Training Physiotherapy Corporate and Executive Medicals Ergonomic Assessments
Fitness Programs In-home Assessments Lifestyle and Health Assessments Lifestyle Programs Motor Vehicle Accident