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Pain Clinic Referral Forms

For healthcare providers

Please select a referral form below.

OHIP Referral Form

For Medical Management, Interventional Procedures, and 8-Day Interdisciplinary 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 note that we do not notify new patients of their Consultation Appointment. A letter with appointment information will be sent to the referring physician. The referring physician will be responsible to notify their patient.

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 Package: For your convenience this package includes everything you need (the referral form and all the forms below)

Referral Form – Brief Pain Inventory

Referral Form – PCS

Referral Form – PHQ-4

Referral Form – Physician

Referral Form – PSEQ

Referral Form – S-LANSS

Referral Form – TSK2

Intensive Pain Program

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 – DND

Referral Form – EMPLOYER

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

We require authorization number from the Treatment Authorization Centre, which they can email to pain@hhsc.ca or fax to 905-521-7975, 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: Susy Faria

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.

Pelvic Pain Program

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

Referral Form – Pelvic Pain