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!

You can fill the forms out on the computer, print and sign. Or you can print and fill out by hand.

Self Pay Patients (no insurance):

   -Please completely fill out forms 1-6.

  1. Patient Information
  2. Financial Policy & Failed Appointment Policy
  3. Sharing Limited Information
  4. Pain Assessment (Page 1), Pain Assessment (Page 2)
  5. Patient Limitations
  6. Health History

 

Insured Patients

– Please completely fill out forms 1-7.

  1. Patient Information
  2. Financial Policy & Failed Appointment Policy
  3. Sharing Limited Information
  4. Insurance ABN
  5. Pain Assessment (Page 1), Pain Assessment (Page 2) 
  6. Patient Limitations
  7. 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. Medicare Voluntary ABN
  5. Sharing Limited Information
  6. Pain Assessment (Page 1), Pain Assessment (Page 2)
  7. Patient Limitations
  8. Health History
  9. Low Back Outcome Assessment
  10. Neck Outcome Assessment

 

Auto Accident Patients:

   -Please completely fill out forms 1-9

  1. Patient Information
  2. Financial Policy
  3. Attorney Lien (only if case is being handled by an attorney)
  4. Auto Insurance Information
  5. Sharing Limited Information
  6. Failed Appointment Policy
  7. Auto Accident Questionnaire (Page 1), Auto Accident Questionnaire (Page 2)
  8. Pain Assessment (Page 1), Pain Assessment (Page 2)
  9. Patient Limitations
  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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