/ / ( ) - ( ) - 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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/ /
( ) - ( ) -
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