To Our New Patients
Our facility requires all patients to be referred by a medical provider before they are accepted as a patient. Our providers will review your records to determine whether or not you will be accepted as a patient. This also allows us to receive all necessary documentation about you before you are seen. Our providers will then be able to create an individualized treatment plan just for you from the first visit.
We also require any previous pain management records also be sent to us before you are approved as a patient.
Before your appointment please fill out the following two documents. The following 6 documents require electronic signatures and will be signed at check-in.
To be filled out prior to appointment
To be signed at check-in
- Patient Information
- Financial Policy
- Phone Call Policy
- Patient Communication Authorization
- Notice of Privacy Practices (Includes Consent for Disclosure to Family)
- Acknowledgement of Notice of Privacy Practices
- Controlled Substance Agreement Form
To Our Referring Physicians
Your referrals indicate your confidence in the treatment your patient will receive from our practice. Your patients are welcomed by our friendly and proficient staff to a pleasant environment and private office setting. We offer a conservative clinical approach to achieve positive long term results for your patient. Every effort is made to communicate with you and keep you continuously updated with each patient encounter. We appreciate the opportunity to provide interventional pain management services for your patients.
- Guidelines for Referrals
- Consult Request
- Authorization for Disclosure of PHI (Medical Records Release)
- Authorization for Disclosure of PHI (Medical Records Request)
- Patient Request for Treatment Release