Pediatric Pain Management Clinic

Tel: (800) 995-5724

You can register for Stanford Medicine Children's Health MD Portal (https://mdportal.stanfordchildrens.org) to submit referrals and track appointments online.

* Required

Referring Provider

Reason for Referral
During your patient’s initial clinic appointment a team of pain management specialists consisting of a physician, nurse practitioner, child psychologist, and pediatric physical therapist will evaluate your patient.

* Please note: A referral is not required for follow up patients with the same diagnosis if they have been seen in the last 2 years.

* Please contact the clinic directly to schedule a follow up appoinment at (650) 497-8977.

 ICD10:

Required CPT Codes to be Authorized for all New Patient Consult Request: 99245  New Patient MD Outpatient Consultation

Required Patient Information
Insurance Information
Document Upload

Please attach the following documents:

  • All relevant clinical documents (i.e. clinic notes, history and progress notes, medication history, growth charts-height and weight, head circumference, labs, diagnostic reports and a copy of the insurance card)
  • Remember to attach authorization.
  • A legible copy of the insurance card (both sides), and authorization if required.

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Attached Files