Forms and Policies

For existing patients:

Please complete pain diagram and bring to your appointment.  If there are any Demographic/Insurance changes or HIPAA updates, please complete and bring to your appointment.  Thank you.

• Patient Demographics
• Pain Diagram
• HIPAA and ARI forms

For new patients:

Please read and complete forms & policies and bring to your appointment.  Please bring your insurance card with you also.  Thank you.

Forms:

• Patient Demographics
• Financial Payment Policy
• HIPAA and ARI forms
• Pain Diagram
• Fax Request for Medical Records
• Card on File FAQs
• COVID 19 Consent to Treatment
• ICC (Portal)
• Interventional Procedure Instructions

Policies:

• Notice of Privacy Practices
• Opioid Policy
• Controlled Substance Agreement
• Opioid Consent for Treatment
• Signature Sheet
• Controlled Substance Policy