Provider Referral & Records Request Form

Call/Text: (602) 456-2860

Fax: (602) 922-2302

About Us:

LoDo Pain provides structured chronic pain medication management, consultation services, transition-of-care support, and telemedicine services throughout Arizona. Referrals are reviewed individually by LoDo Pain providers based on clinical appropriateness, operational capacity, and practice policies.

PATIENT INFORMATION

Patient's First name

Patient's Last name

Patient's Birthday

Month

Day

Year

Patient's Phone

Patient's Email

Patient's Address

REFERRAL INFORMATION

PRIMARY DIAGNOSIS

Current Pain Medications (if any):

Approximate Daily MME (if known):

Additional Clinical Information:

REFERRING PROVIDER INFORMATION

Provider Name

Practice Name

Practice Phone

Practice Email

Practice Fax Number

REQUESTED DOCUMENTATION

Please include the following when available:

Patient Demographics / Face Sheet
Most Recent Office Notes
History and physical
Current medication list
Recent Laboratory Results
Relevant Imaging Reports
Controlled Substance Treatment Agreement (if any)
Arizona CSPMP / PDMP Report (if available)
Other Supporting Documentation

Upload Documents

Upload your file

Choose a file or drag and drop one here.

IMPORTANT NOTICE

Submission of a referral does not guarantee acceptance into the practice. Patients are evaluated through a structured intake and clinical review process. Eligibility, onboarding timing, and treatment decisions are determined by LoDo Pain providers based on clinical appropriateness, patient safety considerations, operational capacity, and practice policies.