Physician Referral - Pain Care Consultants

(318) 629.5505

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Physician Referral

Thank you for your confidence in Pain Care Consultants. We believe in a strong level of communication with our healthcare colleagues and are looking forward to serving you and your patients.

Please refer using one of the following methods

Dedicated referral phone line

You can refer a patient by calling our dedicated referral phone line
(318)629.5435

Dedicated Appointment Fax

Download and fax this form to our dedicated appointment desk fax line
(318)629-5163

Referral Request online

pccnewpatient@msil.md

Use Online Referral Form

Physician Patient Referral

Referring Physician Name(Required)

Phone(Required)

Office Contact Name(Required)

Email(Required)

Enter Email Confirm Email

Referral Type(Required)

Patient Consult

Radiology (CT, MRI, X-Ray)

Patient Name(Required)

First Last

Patient Date of Birth(Required)

MM slash DD slash YYYY

Patient Cell Phone(Required)

Alternate Phone

Reason for Referral(Required)

Insurance(Required)

BCBS

Medicare

Other

Workers Comp

You selected "Other" for Insurance; Please specify.(Required)

You selected "Worker's Comp" for Insurance; Please specify Employer.(Required)

Does the patient have

Current X-Ray report

Current MRI Report

Please make sure the patient brings them with them to their appointment.

PCC Providers(Required)

Please Choose

First Available

Rama Letchuman, MD

Kathleen Majors, MD

Matthew Mosura, MD

Ross Nelson, MD

Please attach or fax (318) 629.5506 all patient demographics, insurance information, radiology reports and last office visit notes to expedite referral.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 2 MB.