Patient Information
Referring Physician

Please download and the complete the Referral Form. Along with the Referral the following must be faxed:
  • PATIENT DEMOGRAPHIC INFORMATION
  • A CLEAR COPY OF THE INSURANCE CARD(s), FRONT AND BACK, SO WE MAY CALL TO CHECK COVERAGE
  • PROGRESS NOTES
  • MRI/SCAN REPORTS
  • PCP's, please send a referral if the patients insurance requires one. If MVA please provide: accident date, insurance company, health coverage
  • IF Work Comp please send: billing address, claim #, pt. attorney, work comp contact name and number
****We do not participate with any State Medicaid Programs.

Physician Referral Form
Note: To view or print these forms, you will need Adobe Acrobat Reader. Click here to download it.

Please Fax to 316-942-4655 - Care of Ashley Starbird

For questions please contact us at 316-942-4519

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©2010 Advanced Pain Medicine Associates. Address: 3715 N. Oliver | Wichita, KS 67220 | Phone: 316-942-4519 | Fax: 316-942-4655 | Emergency: 316-262-6262.