CPM Centres for Pain Management

Central Intake Department Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7

P: 905 288-1022 TF: 800 265-3429 Ext 1022 F: 905 858-0111 TFF: 877 883-3301

CPM Patient Referral Checklist

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

outlined in the checklist:

❑ Fully completed CPM Central Intake Patient Referral Form

❑ Request for Telephone Consultation (if applicable)

❑ Diagnostic Imaging - MRI and CT Reports of the affected areas no older than 5 years

❑ Medical history and list of medications

❑ Relevant consultation, treatments and surgical notes

❑ History of drug/alcohol abuse or addiction

❑ Patient demographics

❑ MD demographic and billing number (see note below)

❑ Other: ________________________________________________________________

IMPORTANT:

Did you know that some of our Centres for Pain Management MD’s have their Focused Based

Practice Designation? This means referring physicians who belong to a FHT, FHO, FHN and

FHG practice model WILL NOT be negated.

Please contact our Central Intake staff if you have any questions or concerns.

CPM Centres for Pain Management Central Intake Department

Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7 P: 905 288-1022 TF: 800 265-3429 Ext 1022 F: 905 858-0111 TFF: 877 883-3301

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. 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 Multidisciplinary 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 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

c. Extent of 3rd

party coverage 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 now a funded service in the OHIP Schedule of Benefits – both for the referring and 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 physicians 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

Central Intake Referral Form

Patient email address if available:

Please circle applicable practice model:

FHT FHG FHN FHO Other

Is this a WSIB Claim? Y N Claim #

MVA Claim? Y N

Is patient receiving Ontario Disability Benefits? Y N

Is patient receiving Long-Term Disability Benefits? Y N

Are you this patient’s family physician? Y N

Patient Medical Profile - Please indicate the clinic you wish your patient to be seen in:

Toronto Mississauga Brampton Scarborough

Oakville Oshawa London Ottawa Hamilton

Specific CPM MD:

Medication advice only? Y N

Request for 10 min MD phone conversation? Y N

If yes, please complete attached Request for Telephone Consultation form

Primary Diagnosis:

Length of pain complaint:

Secondary Diagnosis:

History of alcohol and drug addiction? Y N

Patient’s Past Medical Treatment Profile - Please attach a full list of current medications Has the patient received any of the treatments listed below?

Nerve Blocks NSAIDs/COXIBs Opioids Psychological Counselling Cannabinoids

Tricyclic Other Anti-Depressants Carbamazepine Gabapentin Pregabalin Topiramate

Surgery (What/When):

Interdisciplinary Pain Program (When/Where)

Please attach copies of current MRI and CT reports of the affected areas as well as copies of

relevant consultations, treatments and surgical notes

Patient Alternative Treatment Profile Has the patient received any of the treatments for pain listed below?

Physiotherapy Chiropractic Treatment TENS Acupuncture Naturopathic Massage Therapy

I recognize that my patient is being referred into an interdisciplinary program, and when indicated will

receive care from allied healthcare professionals in addition to care from a physician with pain expertise.

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

patient after discharge.

Physician Signature: Date:

P: 905.288.1022 TF: 800.265.3429 Ext 1022 F: 905.858.0111 TFF: 877.883.3301 www.chronicpainmanagement.ca

Referring MD Information:

Patient Contact Information: For Patient Label

Physician to Physician Telephone Consultation

Physician to physician telephone consultation is a service where the referring physician, 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 physician

The referring physician 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

physician 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.

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

K730 Physician to physician telephone consultation – Referring physician ....................... 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.

Request for Telephone Consultation – Pain Management

Physician 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 MD:

K730 Consulting MD: K731 Diagnostic Code:

AIM Health Group – Health and Wellness Centres

Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7 P: 905 858-1368 F: 905 858-1399

See page 7 of the referral form for a list of our locations or visit www.aimhealthgroup.com.

We have Rehabilitation Services!

The AIM Health Group division of Viable Healthworks offers complementary and alternative

medicine and rehabilitation services at most Centres for Pain Management locations including:

Acupuncture Custom Bracing and Supports Chiropractic Care Kinesiology Massage Therapy Naturopathic Medicine Orthotics and Orthopaedic Shoes Personal Training Physiotherapy Corporate and Executive Medicals Ergonomic Assessments

Fitness Programs In-home Assessments Lifestyle and Health Assessments Lifestyle Programs Motor Vehicle Accident

Rehabilitation Wellness Programs Physical Demands Analysis Pre/Post Employment Testing Return-to-work Programs Work Conditioning/Work Hardening

Our multidisciplinary services and programs include:

Independent Medical Evaluations Functional Abilities Evaluations Work Site Assessment

Interdisciplinary Chronic Pain Assessments

WSIB – Return to Work Coordination Supplements

Did You Know?

We currently offer nutrition and lifestyle counselling programs that may help those who have

obesity, weight management disorders, metabolic syndrome, type II diabetes, hypertension,

PCOS, dyslipidemia, osteoarthritis, obstructive sleep apnea, GERD, and fatty liver. The

programs involve customized nutrition and exercise plans depending on individual need and

may be covered in part by extended health benefits.

CPM Centres for Pain Management

Brampton CPM Oshawa CPM 2 Kennedy Road South, Unit #2 Brampton, ON L6W 3E1 T: 905 458-7377 F: 905 458-7477

1290 Keith Ross Court, 2nd

Floor Oshawa, ON L1H 7K4 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

458 Central Avenue London, ON N6B 2E5 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: 613 731-4770 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 Brampton AIM Ottawa Orleans 2 Kennedy Road South, Unit #2 Brampton, ON L6W 3E1 T: 905 796-2270 F: 905 796-5241

1605 Orleans Blvd, Unit #3 Ottawa, ON K1C 7E2 T: 613 830-6890 F: 613 837-6312

AIM Mississauga AIM London North 6400 Millcreek Drive, Unit #9 Mississauga, ON L5N 3E7 T: 905 858-1368 F: 905 858-1399

267 Fanshawe Park Road West London, ON N6G 5A9 T: 519 645-1222 F: 519 645-1866

AIM Scarborough AIM London South 1200 Markham Road, Suite #425 Scarborough, ON M1H 3C3 T: 416 438-7080 F: 416 438-7072

320 Adelaide Street South London, ON N5Z 3L2 T: 519 668-3969 F: 519 668-1620

AIM Toronto AIM London West 123 Edward Street, Suite #1118 Toronto, ON M5G 1E2 T: 416 593-7700 F: 416 593-7702

1051 Wonderland Road South London, ON N6K 3X4 T: 519 472-2060 F: 519 471-7299

AIM Hamilton AIM London Central 1605 Main Street West Hamilton, ON L8S 1E6 T: 905 529-1222 F: 905 529-9855

458 Central Avenue London, ON N6B 2E5 T: 519 434-4727 F: 519 434-4700

AIM Ottawa Hampton AIM Waterloo 1419 Carling Avenue, Suite #216 Ottawa, ON K1Z 7L6 T: 613 731-4770 F: 613 728-5295

153 Union Street East Waterloo, ON N2J 1C4 T: 519 725-4424 F: 519 725-2320

AIM Ottawa Trainyards AIM Kitchener 550 Terminal Avenue, Unit #B22 Ottawa, ON K1G 0Z3 T: 613 731-4770 F: 613 731-4979

550 King Street East Kitchener, ON N2G 2L8 T: 519 749-2222 F: 519 749-8937