Independent Spine Network
Direct Injection Referral Pathway
Does the patient have red flag symptoms (bowel or bladder incontinence, saddle anesthesia, progressive weakness, unintentional weight loss, unexplained fevers/chills)?
*
Yes
No
If the patient has red flag symptoms, we recommend evaluation at the Emergency Department.
Which health insurance does the patient have? If the patient doesn't have one of the following they can still be referred directly for an injection if they would like to self-pay.
*
BCBS ND
Sanford Health Plan (non-employee)
Original Medicare (not Medicare Advantage/Replacement)
Self Pay option: $850 due at the time of service
In order to qualify for the direct injection referral pathway, the patient must meet all of the following criteria. Please select all that apply.
*
Pain is present for greater than or equal to 4 weeks
MRI of cervical or lumbar spine already completed
In order to qualify for the direct injection referral pathway, the patient must meet one of the following criteria. Please select all that apply.
*
Physical therapy is possible despite pain level but the patient has reached maximum potential benefit without further intervention OR Appropriate physical therapy management is not possible due to significant pain level
Chiropractic care is possible despite pain level but the patient has reached maximum potential benefit without further intervention OR Appropriate chiropractic care is not possible due to significant pain level
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How many weeks has the patient had the pain?
*
Where was the MRI performed?
*
Institute of Diagnostic Imaging
Sanford
Essentia
Other
How many physical therapy sessions has the patient completed?
*
How many chiropractic sessions has the patient completed?
*
Where is the pain located?
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Cervical Spine
Lumbar Spine
Which extremity does the pain radiate into?
*
Right
Left
Bilateral
Which Cervical Dermatome(s) are primarily affected?
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C4
C5
C6
C7
C8
Which Lumbar Dermatome(s) are primarily affected?
*
L1
L2
L3
L4
L5
S1
On a scale of 1-10 how does the patient rate the pain on average?
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Minimal Pain
1
2
3
4
5
6
7
8
9
Worst Pain Ever
10
1 is Minimal Pain, 10 is Worst Pain Ever
Which of the following apply to this patient (select all that apply)?
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Patient has tried home exercise program
Patient has tried over the counter pain medication (NSAIDs or Tylenol)
Patient has tried chiropractic care or massage therapy
Patient has tried prescription pain medication
Patient has sought care in the Emergency Department or Urgent Care
Patient is missing work due to the pain
Patient is having significant sleep disruption due to the pain
Patient has evidence of neurologic deficit (weakness, loss of sensation, reflex abnormality) on physical examination
Patient takes blood thinners
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Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider Name
*
First Name
Last Name
Referring Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider Location
*
Please Select
RehabAuthority
ProRehab
701 Chiropractic
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