Pain Clinic Referral Forms

For Medical Management, Interventional Procedures, and 8-Day Pain Management Program.

To be referred to the Michael G. DeGroote Pain Clinic, patients must have a Family Physician. For patients who do not have a family physician, Health Care Connect refers Ontarians to a family health care provider who may be accepting new patients

Please complete the appropriate Referral Form below, including the questionnaires and fax to 905-577-8022.

We recommend all non-urgent OHIP referred patients attend the Chronic Pain Self Management Program.

Referral Form: The Referral form is to be completed by the referring provider and faxed along with any relevant clinical and/or diagnostic reports. IMPORTANT: If the patient is to be considered for interventional treatment of any area of the spine, we require a recent CT or MRI (no older than a year).

This program is not covered by OHIP. Referrals accepted from Physicians, Veterans Affairs, WSIB, Insurance Companies, Employers, Lawyers, Community Rehabilitation Health Professionals, etc. To participate in this program, an individual must attend an assessment at this facility.

Please select the appropriate referral form below, and after completion please fax to 905-521-7975.

Referral Form – Insurance

For Motor Vehicle Accident (MVA) referrals: Once we receive the referral, one of our health professionals will contact the patient to complete a screening and gather the information to complete the OCF-18 (application for treatment and assessment). We will send the OCF-18 to the patient for their review and signature, and then submit to the insurance company for their approval. Once funding is secured, we will contact the referring agency and/or lawyer for the appropriate medical documentation, and an assessment will be scheduled.

For all other insurance claims, we require written authorization prior to scheduling an assessment.

Referral Form – Veteran Affairs

Referral Form – DND

We require pre-authorization from the Treatment Authorization Centre, prior to booking an appointment for your client. Upon receipt of the referral, we will send you a cost summary, which would include the details about our provider number and service code for Medavie Blue Cross. Authorization numbers can then be emailed to cpmu@hhsc.ca or faxed to 905-521-7975, in order to facilitate an appointment.

Referral Form – WSIB

If we are not successful obtaining funding for your patient, we will notify your office. If you have any questions regarding the referral process please contact us:

Phone: 905-521-7931
Toll-free: 1-888-243-3653
Email: pain@hhsc.ca

Please note: to be eligible for our service, treatment costs must be authorized by an insurance company, WSIB, Veteran Affairs, DND, or other funding agency.

A referral from your gynecologist, urologist or pain physician is required.

Referral Form – Pelvic Pain