Chronic Pain Management Patient InformatioN

Pain Injections by Referral from your physician

To schedule pain injections with Dr. Richard Alessi have your referring physician fax the following information to the attention of Acute Pain Scheduler at 970-488-1646:

  PATIENT DEMOGRAPHICS:
   - Name
   - Address
   - Phone Numbers
   - Date of Birth
   - Social Security Number
   - Emergency Contact
  INSURANCE CARRIER(S):
   - Copy of Insurance Card(s)
   - Name of Policy Holder, Member and Group Numbers, Provider Pre-certification Telephone Numbers
   - DOB of cardholder (if other than the patient)
 MEDICAL HISTORY: 
   - Clinical Notes including Diagnosis (ICD-9 code) Reason for Referral (type of procedure recommended and what levels suggested for injection).
   - Related Surgical Dictations
   - Related MRI Reports
   - Rx and Over the Counter Medications currently being taken
   - Drug Allergies

Comprehensive pain management services are provided by Front Range Pain Management at their office:

Front Range Pain Medicine
3744 South Timberline Road, Suite 102
Fort Collins, CO 80525

(970) 495-0506
www.frpmedicine.com