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Spinal Surgery
Laser Spine Center
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Complete Spine & Joint Injury Specialist!
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Scheduling:
770.997.0600
Fax in request: 678.565.3625
Email in request:
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Locations
Stockbridge
Decatur
Newnan
College
Marietta
Referral Information
Date
Patient Name
*
First
Last
Date of Birth
Phone
Chief Complaint
Treating Provider
Treating Phone
Referral for:
E&M
E&M w/ MRI if needed
Surgical Consult
Pain Management
NCV/EMG
Upper Extremity
Lower Extremity
R
L
Bilateral
MRI
Other
**Please attach most current office note for proper precertification.
MRI Area
Other
Policy Information
Insurance Carrier
Policy #
Accident Related:
Yes
No
Date of Accident
Attorney Representation:
Yes
No
Law Firm:
Work Related:
Yes
No
Date of Injury:
Case Manager Name
Case Manager Phone
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