Patient Paperwork

It is important for us to gain as much information about your health that we can.  This information helps us to give you the best of care.  The following forms need to be completely filled out for new or established patients requiring an examination. If you choose to complete the forms in our office before your appointment, please arrive 15 minutes early. Thank you!

New and Established Patients:

   -Please completely fill out forms 1-6

  1. Patient Information
  2. Financial Policy & Failed Appointment Policy
  3. Permission to Share Limited Information
  4. Pain Assessment (Front), Pain Assessment (Back)
  5. Patient Restrictions
  6. Health History

Medicare  Patients:

   -Please completely fill out forms 1-10

  1. Patient Information
  2. Financial Policy & Failed Appointment Policy
  3. Notice of Medicare Coverage
  4. Voluntary Medicare ABN
  5. Permission to Share Limited Information
  6. Pain Assessment (Front), Pain Assessment (Back)
  7. Patient Restrictions
  8. Health History
  9. Low Back Disability Questionnaire
  10. Neck Pain Disability Questionnaire

Auto Accident Patients:

   -Please completely fill out forms 1-9

  1. Patient Information
  2. Auto Accident Questionnaire (Front), Auto Accident Questionnaire (Back)
  3. Doctor’s Lien (only if case is being handled by an attorney)
  4. Auto Accident Insurance Information
  5. Auto Financial Policy
  6. Permission to Share Limited Information
  7. Failed Appointment Policy
  8. Pain Assessment (Front), Pain Assessment (Back)
  9. Patient Restrictions
  10. Health History

 

Notice of Privacy Practices: Privacy Practices (Page 1), Privacy Practices (Page 2), Privacy Practices (Page 3), Privacy Practices (Page 4)

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