How to Refer to CC4PM

The providers at CC4PM thank you for referring your patients to our practice and look forward to taking care of them as quickly as possible. We have helped streamline the referral process for pain management patients, and will work with your staff to make the transition of care as easy as possible. We will send you a consultation report after your patient's visit to CC4PM as quickly as possible.

Referral Process

1. Download and fill out the patient referral form located below;
2. Fax this referral form to 419-754-5870
3. Please include patient information and notes related to the referral, including:

  • All radiology/imaging reports
  • Latest dictation
  • Medication sheet
  • Copy of patient data sheet
  • Any pre-certification paperwork (or C-9 for BWC cases)

Download Patient Referral Form Here

Fax to CC4PM at 419-754-5870

Thank you for your referral. If you have any questions, please contact our Patient Care Coordinator at 419-346-1076.

Contact us to learn more about how we can help at 1.877.446.6742