P: 905.288.1022 TF: 800.265.3429 Ext 1022 F: 905.858.0111 TFF: 877.883.3301 www.cpm-centres.com

Last updated December 2017

CPM Patient Referral Checklist

To optimize our central intake and referral process please include ALL required information

outlined in the checklist:

❑ CPM Patient Referral Form – see page 3 or you may also use your own referral form.

❑

If using your own referral form it must include the below listed information. Please sign and fax the below statement along with your referral:

I acknowledge and I agree to resume care for this patient after discharge.

Primary Care Practitioner Signature: ____ Date:

❑ Cumulative Patient Profile (CPP)

❑ Diagnostic Imaging – MRT and/or CT Report

❑ Medical history and list of medications **Send this if CPP not attached**

❑ Relevant consultation, treatments and surgical notes

❑ History of substance abuse or addiction

❑ Patient demographics

❑ Primary Care Practitioner name, demographic and billing number (see note below)

❑ Request for Primary Care Practitioner to Physician Telephone Consultation (OHIP Funded Service)

Telephone Consultation

A service where the referring primary care practitioner requests the opinion and expertise of a CPM

physician. It allows the PCP the opportunity to ask questions regarding their patient with chronic pain so

they can;

a) Continue providing ongoing treatment and/or;

b) Refer them to a CPM pain clinic.

Refer to page 4 for payment rules and form.

IMPORTANT: Did you know that most of our Centres for Pain Management MD’s have their Focused Based Practice

Designation? This means referring primary care practitioners who belong to a FHT, FHO, FHN and HSO

practice model WILL NOT be negated.

Roman D Jovey MD

Medical Director

Dear Primary Care Practitioner, Thank you for referring your patient with chronic pain to one of our CPM centres for assessment and/or treatment. I would like to highlight some of the benefits our centres can offer you and your patients.

Centralized Intake Process: We have a Centralized Intake Process to standardize screening of each referral. This process ensures that all required information for the consultation has been received. The efficiency of this process helps us to see your patient on a timelier basis. For specialists, please be advised that CPM will facilitate the co-sign from the patient’s primary care physician or nurse practitioner. Timely Assessment of Sub-Acute Pain: The earlier a patient with pain is treated, the more likely a successful outcome will occur. Painful conditions treated within the first 3-6 months using a multimodal approach have the highest chance of full recovery. Patients with pain for more than 18 months can typically expect some reduction in pain and improvement in the quality of life, but it is unlikely their condition will be resolved. We therefore try to prioritize patients with sub-acute pain. Timely Access to Treatments: Our goal is to provide comprehensive, caring, chronic pain management whenever possible. Many components of multidisciplinary care are not funded by OHIP. CPM will provide the Stanford-based, 6-week, Chronic Pain Self-Management Program to all CPM patients at no charge. For patients with supplemental health coverage, we can provide referrals to other elements of comprehensive care: exercise, massage, cognitive-behavioural therapy, and nutrition counselling etc. For patients without coverage we may refer to community and online resources. New patient referrals to CPM will be prioritized based on:

a. The need for a one-time consultation vs. a period of active care

b. Duration of the painful condition

Telephone Consultation: We offer the option of a brief telephone consultation, to better support primary care practitioners (PCPs) whose patients might have to wait to be seen at our centres. This is a funded service in the OHIP Schedule of Benefits – both for the referring primary care practitioner and the consulting physician. It is suitable for a patient with chronic pain, where there are a small number of specific questions to help the PCP continue ongoing treatment. A specific 1-page referral form can be sent at your request. You can also request telephone consultation patients currently under the care of a CPM physician.

We continually strive to improve our service offerings to referring PCP and patients with pain. Please contact our central intake staff if you have any questions or concerns about referring your patients to CPM.

CPM Centres for Pain Management Referral Form

P: 905.288.1022 TF: 800.265.3429 Ext 1022 F: 905.858.0111 TFF: 877.883.3301 www.cpm-centres.com

Patient email address if available:

Please check applicable practice model:

FHT ☐ FHO ☐ FHG ☐ FHN ☐ FFS ☐ HSO ☐

Patient Medical Profile – Please select the preferred clinic location for your patient

Toronto Mississauga Brampton Scarborough Oakville Oshawa London Ottawa Hamilton

Specific CPM MD:

Primary Diagnosis: _____________________ Secondary Diagnosis: _____________________

Length of pain complaint: ________________ History of substance use disorders? Y ☐ N ☐

Has the patient been to a pain clinic? Y ☐ N ☐ If yes, please attach all relevant correspondence

I acknowledge that I have read the conditions of this referral and I agree to resume care for this patient after discharge.

Primary Care Practitioner Signature: Date:

P: 905.288.1022 TF: 800.265.3429 Ext 1022 F: 905.858.0111 TFF: 877.883.3301 www.cpm-centres.com

Last Updated December 2017

Primary Care Practitioner Information:

Patient Contact Information:

Are you this patient’s primary care practitioner? Y ☐ N ☐

Are you willing to de-roster your patient? Y ☐ N ☐

If no, who is the primary care practitioner? _____________

To expedite the referral please ensure the following is attached:

Copy of your Cumulative Patient Profile (CPP)

Relevant imaging

Relevant consultation reports

List of current medications

Request for 10 min MD phone conversation? Y N If yes, please complete attached Request for Telephone Consultation form

Medical advice only? Y ☐ N ☐ Is the primary reason for this referral a request for medical cannabis? Y ☐ N ☐

Is the primary reason for this referral a patient request for pain infusion? Y ☐ N ☐ (Available in Oshawa clinic only)

Is the primary reason for this referral to request a second opinion? Y ☐ N ☐

FHO, FHT will not be negated

Primary Care Practitioner (PCP) to Physician Telephone Consultation

Primary care practitioner to physician telephone consultation is a service where the referring primary care

practitioner, in light of his/her professional knowledge of the patient, requests the opinion of another physician

(the “consultant physician”) by telephone who is competent to give advice in the particular field because of the

complexity, seriousness, or obscurity of the case. This service is only eligible for payment if the consultant

physician has provided an opinion and/or recommendations for patient treatment and/or management. For the

purpose of this service, “relevant data” include family/patient history, history of the presenting complaint,

laboratory and diagnostic tests, where indicated and feasible in the circumstances.

Definition/Required elements of service – Referring Primary Care Practitioner

The referring primary care practitioner initiates the telephone consultation with the intention of continuing the

care, treatment and management of the patient. In addition to the Constituent and Common Elements of

Insured Services described in the General Preamble of this Schedule, this service includes the transmission of

relevant data to the consultant physician and all other services rendered by the referring primary care

practitioner to obtain the advice of the consultant physician. Note: This service is eligible for payment in

addition to visits or other services provided to the same patient on the same day by the same referring

physician.

Definition/Required elements of service – Consultant physician

This service includes all services rendered by the consultant physician to provide

opinion/advice/recommendations on patient care, treatment and management to the referring physician or

nurse practitioner. The consultant physician is required to review all relevant data provided by the referring

primary care practitioner.

K730 Physician to PCP telephone consultation – Referring PCP ......................................... 31.35

K731 Physician to physician telephone consultation – Consultant physician .................... 40.45

Payment rules:

1. A maximum of one K730 service is eligible for payment per patient per day.

2. This service is only eligible for payment for a physician to physician telephone consultation service:

a. that includes a minimum of 10 minutes of patient-related discussion for any given patient, and;

b. where the referring physician and consultant physician are physically present in Ontario at the time

of the service.

Medical record requirements:

Physician to physician telephone consultation is only eligible for payment where the following elements are

included in the medical record for a physician who submits a claim for the service:

1. Patient’s name and health number; 2. Start and stop times of the discussion; 3. Name of the referring and consultant physicians; 4. Reason for the consultation, and; 5. The opinion and recommendations of the consultant physician.

Claims submission instructions:

K731 is only eligible for payment if the consultant physician includes the referring physician’s billing number

with the claim.

Last updated October 2017

Request for Telephone Consultation – Pain Management

Primary Care Practitioner Name: OHIP Billing No.

Back Line Telephone No. Best time on Tuesday to call:

Patient Name:

DOB: HCN:

Brief history of the pain problem and current treatments (attach additional pages if required):

Specific questions to discuss:

Date of discussion: Start – Stop times:

Record of issues discussed / advice given:

Billing: - Referring PCP: K730

Consulting MD: K731 Diagnostic Code:

CPM Centres for Pain Management

Brampton CPM Oshawa CPM 312 Queen Street East Brampton, ON L6V 1C2

T: 905 458-7377 F: 905 458-7477

500 King Street West, Unit #2 Oshawa, ON L1J 2K9

T: 905 576-3444 F: 905 576-7980

Mississauga CPM Oakville CPM 6400 Millcreek Drive, Unit #9 Mississauga, ON L5N 3E7

T: 905 288-1045 F: 905 858-0111

2125 Wyecroft Road, Unit #6 Oakville, ON L6L 5L7

T: 905 842-7051 F: 905 842-8216

Scarborough CPM London CPM 1200 Markham Road, Suite #425

Scarborough, ON M1H 3C3 T: 416 438-7080 F: 416 438-7072

215 Fanshawe Park Road West, Suite #203 London, ON N6G 5A9

T: 519 434-4727 F: 519 434-4700

Toronto CPM Ottawa CPM 123 Edward Street, Suite #1118

Toronto, ON M5G 1E2 T: 416 593-7700 F: 416 593-7702

550 Terminal Avenue, Unit #B22 Ottawa, ON K1G 0Z3

T: 613 755-2095 F: 613 731-4979

Hamilton CPM 1605 Main Street West Hamilton, ON L8S 1E6

T: 905 574-4911 F: 905 574-8290

AIM Health Group – Health and Wellness Centres

AIM Toronto AIM Hamilton 123 Edward Street, Suite #1118

Toronto, ON M5G 1E2 T: 416 593-7700 F: 416 593-7702

1605 Main Street West Hamilton, ON L8S 1E6

T: 905 529-1222 F: 905 529-9855

AIM Scarborough AIM Kitchener 1200 Markham Road, Suite #425

Scarborough, ON M1H 3C3 T: 416 438-7080 F: 416 438-7072

550 King Street East Kitchener, ON N2G 2L8

T: 519 749-2222 F: 519 749-8937