Healthcare Providers Directory for Pain Management, Missouri Pain Initiative (MOPI)

Missouri Pain Initiative a State Member of the American Alliance of Cancer Pain Initiatives

July 4, 2008

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Provider Directory Submission

If you wish to be listed in our online directory of pain providers, complete the survey below. Once we have verified your submission, you will be including in the listing.

Organization:

Address:

City:

State:

Zip:

Phone:

Email:

Staff:

Disciplines:

Please check all that apply.

	Alternative and Complimentary Therapies		Osteopathy
	Anesthesia		Palliative Care
	Chiropractic Medicine		Physical Medicine & Rehabilitation (Physiatrist)
	Family Practice		Physical Therapy
	Internal Medicine		Psychiatry
	Neurology		Psychology
	Occupational Therapy		Social Work
	Orthopedics

Other:

Practice:

What best describes your practice setting? Please check all that apply.

	Academic
	Hospital-based Community
	Hospital-based Academic
	Private Practice
	Rural
	Suburban
	Surgicenter/Outpatient/Home based
	Urban

Other:

Conditions:

	Arthritic Pain		Migraines
	Cancer Pain		Multiple Sclerosis
	Causalgia		Myofascial Pain
	Central Pain		Nerve Injuries
	Cervicogenic Pain		Neuropathic Pain
	Complex Regional Pain Syndromes		Phantom Limb Pain
	Crohn's Disease/Colitis		Radiculopathies
	Cystic Fibrosis		Reflex Sympathetic Dystrophy
	Diabetic Peripheral Neuropathies		Sciatica
	Fibromyalgia		Sickle Cell Anemia Pain
	Headaches - cluster		Spinal Cord Injuries
	Headaches - other types		Temporomandibular Joint Dysfunction
	HIV/AIDS		Thoracic Outlet Syndrome
	Lumbago - lower back pain		Vascular Pain
	Lupus

Other:

Services

Noninvasive:

What services do you offer? Please check all that apply.

	Acupuncture		Osteopathic Medicine
	Aromatherapy		Patient Education
	Biofeedback		Pharmacological
	Chiropractic		Physical Therapy
	Massage		Psychological Services
	Naturopathic Medicine		Therapeutic Touch
	Occupational Therapy

Other:

Invasive:

	Epidural Medications
	Nerve Blocks
	Spinal Cord Stimulators
	Intrathecal Pumps

Other:

Referrals:

Do you require a referral from another physician:
Yes No

Do you accept:

Medicare: Yes No

Medicaid: Yes No

Other Insurance: Yes No

Membership:

Are you currently a dues-paying member of the Missouri Pain Initiative?
Yes