Paradigm Outcomes
Complex Pain Solution Referral Form
Please complete referral form as accurately and completely as possible. Please be aware you are responsible for the protected
health information contained in this form. Please take the appropriate steps to submit this form in a secure manner.
1.
2.
Submit referral form and signed release of information form to fax # 925-676-2197 or e-mail to referrals@paradigmcorp.com
Forward the last two (2) years of medical records (see below for details) and the last two (2) years medical spend
ACCOUNT INFORMATION:
COMPANY:
I AM THE
EMPLOYER
CARRIER
TPA OTHER
REFERRAL DATE:
CLAIM REP:
ADDRESS:
PHONE:
EMAIL:
OTHER CONTACT:
COMPANY:
PHONE:
EMAIL:
CLAIM INFORMATION:
CLAIM STATUS:
MMI HAS BEEN REACHED
CLAIM/FILE #:
INDEMNITY IS SETTLED
IW HAS RETURNED TO WORK
DATE OF INJURY:
CLAIMANT NAME:
PHONE:
JURISDICTION (STATE):
SSN #:
ADDRESS:
LEGAL REPRESENTATION:
ZIP:
YES
OTHER
NO
STATE OF RESIDENCE:
DATE OF BIRTH:
MARITAL STATUS:
PRIMARY LANGUAGE: English
PATIENT SEX:
APPROVAL RECEIVED FROM ATTORNEY FOR PARADIGM INVOLVEMENT:
ATTORNEY NAME:
FIRM NAME:
ADDRESS:
PHONE:
FAX:
M
YES
F
NO
EMAIL:
CURRENT PRIMARY PHYSICIAN(S) FOR THIS ILLNESS/INJURY: (PLEASE ATTACH THE CURRENT TREATING PROVIDER’S MOST RECENT OFFICE NOTE. ADDITIONALLY, PLEASE
PROVIDE INFORMATION ABOUT ALL KNOWN ACTIVE TREATING PHYSICIANS USING THE TABLE BELOW)
PRESCRIBING PHYSICIAN NAME:
SPECIALTY:
PHONE #:
PHYSICIAN ADDRESS:
FAX NUMBER:
PHYSICIAN NAME:
SPECIALTY:
PHONE NUMBER:
PHYSICIAN ADDRESS:
FAX NUMBER:
PHYSICIAN NAME:
SPECIALTY:
PHONE NUMBER:
PHYSICIAN ADDRESS:
FAX NUMBER:
CURRENT MEDICATION LIST (PLEASE ATTACH CURRENT PHARMACY UTILIZATION REPORT. IF THAT REPORT IS NOT IMMEDIATELY AVAILABLE, PLEASE PROVIDE THE MOST
RECENT MEDICATION INFORMATION BELOW AND SUBMIT THE PHARMACY UTILIZATION REPORT AT YOUR EARLIEST CONVENIENCE)
MEDICATION NAME
DOSAGE
FREQ
WORK INJURY RELATED/ACCEPTED DIAGNOSES:
MEDICATION NAME
CHRONIC PAIN
DOSAGE
FREQ
MEDICATION NAME
DOSAGE
FREQ
OTHER
CURRENT TREATMENT AND GOALS FOR REFERRAL
Medical Records: Forward the last two (2) years of medical records, including: Diagnostics, admission/discharge reports for any major
hospitalizations and surgical procedures; IMEs or any specialty evaluations, therapy notes, counseling/psych reports; case management reports, life
care plans/MSAs
Medical Paid: Last (2) years – $
NOTE: Paradigm’s services are limited to providing the carrier/client and its agents an overview of the attending physician’s plan of care. This service is not
intended to function as a form of utilization review or comment on appropriateness of care. By virtue of the attending physician inquiry, Paradigm’s Medical Director
will not be authorizing services nor providing adverse determinations.
The information contained in this facsimile document may contain information that is privileged, confidential, and exempt from disclosure under applicable law, and is intended only for the use of the individual or entity named below. If the reader of
this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If
you receive this communication in error, please notify us immediately by telephone at 800-676-6777 Attn: Referral Intake Coordinator for return instructions.
PROPRIETARY AND CONFIDENTIAL. ALL RIGHTS RESERVED 2014.
Authorizing Agent’s Company Name:
Release of Information and Injured Worker Management Authorization
Injured Worker
Social Security #
Date of Birth
Date of Loss
(Authorizing Agent’s Company Name)
authorizes the release of information to Paradigm and its Representatives
to complete the assessment of the above named individual. In addition, (Authorizing Agent’s Company Name)
authorizes Paradigm to initiate medical case management including an on-site assessment and collection of available
medical and personal information. For purposes of this Release of Information and Injured Worker Management
Authorization, “Representative” shall mean a managed care vendor providing services to Paradigm. This release applies
to all available medical, personal and/or mental health information, including, but not limited to:

Physician’s History and Physical Therapy
Evaluations

Nursing Assessment and Most Recent Week’s
Notes

Progress Reports

Surgical Reports

Discharge Reports

Current Medications

Medical/Neurological Consult Reports

Rehabilitation Team Conference Reports

Neuropsychological Test Data

Discharge Summaries

Neuropsychological Evaluation/Reports

School Records

Itemized Bills

Legal Records

Diagnostic Tests and Results

Personal information
The authorization is subject to revocation by the undersigned at any time except to the extent that action has already
been taken. This information has been disclosed to Paradigm from records whose confidentiality is protected by various
state laws. Any further disclosure of this information shall be in accordance with all applicable laws. A photocopy of this
authorization is to be accepted with the same authority as the original.
Authorizing Agent’s Signature
Date
Paradigm Management Services, LLC and its Representatives
Attention: Clinical Services
1277 Treat Blvd. #800
Walnut Creek, CA 94597
The information contained in this facsimile document may contain information that is privileged, confidential, and exempt from disclosure under applicable law, and is intended only for the use of the individual or entity named below. If the reader of
this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If
you receive this communication in error, please notify us immediately by telephone at 800-676-6777 Attn: Referral Intake Coordinator for return instructions.
PROPRIETARY AND CONFIDENTIAL. ALL RIGHTS RESERVED 2014.
Special Jurisdictional Considerations
In general, Paradigm’s first step following a Complex Pain referral is our Physician Consultative Services (PCS) module, in
which a Paradigm Medical Director works with the Injured Worker’s treating provider. There are some states in which
there are special requirements to initiate PCS. The table below outlines Paradigm’s guidance to clients around referrals
based on Paradigm’s understanding of prevailing jurisdictional requirements. In the event your organization interprets
jurisdictional requirements differently, Paradigm is open to discussing and reconciling. Please direct any questions to
your primary Paradigm contact.
States
Process
All except those
listed below
Physician Consultative Services (PCS) is the first step in Paradigm’s management process. No special action is
required.
AK, LA, MN, NH
PCS is not offered due to state regulations. Referrals move directly to Paradigm Team Management (PTM).
CT, DE*, IL, KY*,
MD, MI, MT, NV,
NM, NC, ND, PA,
SC, SD, TN*, UT*,
VT*
PCS is offered. To proceed with PCS, Paradigm requires a release from the Injured Worker allowing Paradigm
to contact the treating provider. Paradigm will accept a release previously obtained by our customer and
signed by the injured worker.
* Special rules

If there is already a signed release in the file, please let Paradigm know at the time of referral by alerting
the Referral Intake Coordinator: Paradigm will then proceed with PCS.
 If there is not already a signed release, please let Paradigm know if you will attempt to obtain one:
– Once the release is obtained, please let Paradigm know by alerting your primary Paradigm contact:
Paradigm will then proceed with PCS.
– If a release cannot be obtained, referrals move directly to Paradigm Team Management (PTM)
DE: Also requires attorney approval, if an attorney is involved
KY:
The IW release must be documented using the State-specific “106 Waiver and Consent” form
TN:
The IW release must be documented using the State-specific “ROI C31” form.
UT:
The IW release must be documented using the State-specific HIPPA Authorization form
VT:
The IW release must be documented using the State-specific “DOL Form 7” form
The information contained in this facsimile document may contain information that is privileged, confidential, and exempt from disclosure under applicable law, and is intended only for the use of the individual or entity named below. If the reader of
this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If
you receive this communication in error, please notify us immediately by telephone at 800-676-6777 Attn: Referral Intake Coordinator for return instructions.
PROPRIETARY AND CONFIDENTIAL. ALL RIGHTS RESERVED 2014.