Fast Track Scheduling
SMPC Scheduling phone: 877-377-6227
Email: referrals@procaresystems.com
Additional med recs can be emailed to address above or faxed to : 800-940-9601

To print a copy for your records, fill out then hit File > Print, from the File Menu before you select 'Submit this Form'

Please complete this form and click 'submit by email' above. Our scheduling department will call the patient to set up appointment and then call you to let you know appointment has been set.Yellow indicates required information. Thank you for the referral.

Date: Patient Name:
Social Security No: Date of Birth: Home Phone No:
Referring Physician: Phone No (Required): Fax No:
Referring Office Contact: PCP (if not referring Dr):
PCP Phone No: Referring Office e-mail:
Face Sheet to be emailed separately Insurance Info is included on this email
Marital Status:    Single    Married    Divorced    Widowed     Spouse's Name:
Patient Address:
Employer:
Is this Work or Auto related?  No  Yes, if yes, please provide the Claim No:
Date of Injury: Insurance Carrier:
Adjuster Name: Phone No:
Primary Insurance:
Contract No: Insured Name:
Group No: Employer:
Secondary Insurance:
Contract No: Insured Name:
Group No: Employer:
Reason for Referral:
Explanation:
Notes:
 Evaluate Only  Physical Therapy
 Evaluate and Treat  Behavioral Therapy
 Discogram  Post Surgical Complications
 Medication Treatment Plan  Return to Work Issues
 IME/Disability Assessment   One Block/Epidural Only
Previous Studies/Treatments and Location where Performed:
X-Ray     When? Where?
CT Scan   When? Where?
MRI         When? Where?
Discogram When? Where?
Other         When? Where?
Pain Management, Where? Who?
APPOINTMENT SCHEDULED: PACKET SENT: EMPLOYEE INITIALS:
Time: Date: PHYSICIAN: LOCATION:
     
UPLOAD MEDICAL RECORD    
Should be < 3MB (allow *.jpg, *.pdf,*.gif and *.doc)
If you are receiving transmission errors or have questions, please call (616) 940-2662 ext. 1576 or (800) 281-3237 ext. 1576.
Form will not send if yellow areas are not all filled in