• Patient Information

  •  / /

  • Referrer Information

  • Örebro Musculoskeletal Pain Screening Questionnaire

    Based on ACC Örebro form from Linton & Hallden, 1998

  • ACC Provider Referral for Pain Management

    Please fill out the additional details below to generate a completed ACC6273 provider referral for pain management form. This form will be attached to the automated email you receive once you have pressed send.

  • 1. Client Details

  • Known barriers or special considerations

  • Please note details, e.g. if a barrier, note any existing or recommended support.

  • 2. Referrer Details

  • 3. ACC Contact Details

    (if known)

  • 4. Why I'm Making this Referral

    Please let us know why you’re making this referral for the Pain Management Service. Include advice on how the clients current pain concern is linked to covered injury(s).

  • 5. Service Level Required

    Please let us know the type of service required.
  • Service Level

  • The Pain Management Service supplier will contact ACC to seek approval.

  • Please send a copy of all reports to ACC.

  • Please provide all supporting medical information available.

  • Please send a copy of any reports.

  • 6. Injury Details

  •  / /

  • 7. Injury Management and Rehabilitation

    Describe the management and rehabilitation provided to date.

  • 8. Relevant Contact Details

    Please list who was involved with this client’s rehabilitation.

  • Treating General Practitioner (GP)

  • Employer or School

  • Specialist

  • Physiotherapist

  • Psychologist

  • Other

  • 9. Attached Documents

    Please list all the documents you’re attaching to this referral. For example clinical notes, radiology reports etc.
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