All clinic forms must be updated annually. To reduce waiting time patients can download our forms then bring them completed to your next appointment.
Forms
- PHI Use & Disclosure – Releasing Information
- PHI Use & Disclosure – Receiving Information
- HIPAA Notice of Privacy Practices
- Informed Consent for Telemedicine Services
- Narcotics Policy
*All other patient forms may be obtained through the patient portal or by stopping by the clinic.
Disability and/or workers’ compensation forms should be filled out and signed prior to being delivered to the office. The provider portion will be completed and mailed to the appropriate entity within five business days of receipt.
New Patient Information
- Please arrive 30 minutes early if you have never been seen at our office to complete necessary paperwork.
- Current insurance cards – If you have no insurance, a minimum of $350 will be collected at the time of your appointment.
- Driver’s license or other photo ID to be scanned into your file in order to protect your identity.
- Personally bring x-rays, test results, and records from other physicians if pertinent to the visit. We cannot always depend on others to get this information to the office in time for your appointment.
- List of your medications and herbal supplements with dosages.
- List of your allergies and the kind of reaction you have had to each medication.
- Co-pay for your visit as required by your insurance. We accept cash, check, MasterCard, Visa, and Discover.
- A copy of the first report of your injury including your workers’ comp claim number.
- Health insurance information – This will protect you if workers’ compensation contests or denies your claim. We can at that point bill your insurance company. Otherwise, the bill becomes your responsibility.
- Please Note: If workers’ compensation never contests or denies your claim for this injury, then we will not use your health insurance information. It is for your protection.