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 905-577-8022.
Insurance Referral Form
- 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.
Veteran Affairs Referral Form
- We require authorization number from the Treatment Authorization Centre, which they can email to firstname.lastname@example.org or fax to 905-577-8022, or mail to Michael G. DeGroote Pain Clinic, McMaster University Medical Centre, 4th Floor Yellow Section 4V, 1200 Main St. W., Hamilton, ON, L8N 3Z5, Attention: Sonya Altena.
Department of National Defence Referral Form
WSIB Referral Form
Employer Referral Form
Physician Referral Form
- 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:
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.