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New Patient Forms

New Patient



New Patient

Health History  


Record Release

Fax referral for referring 

physician office use

Frequently Asked Questions

What do I need to bring to my first appointment?

Please bring the following:

1. Printed and completed ' NEW PATIENT ' forms (above)

2. Your Insurance card

3. Your Photo ID or Drivers License

4. Medication list, any Xray, MRI or lab reports you have.

5.  Payment for COPAY , Deductible

6. If you have a HMO plan or WC injury case, you will need an authorization number prior to your first visit.


What is CoPay?

Each insurance assigns a fixed amount that patient must pay at time of service. Copay amount is not billed and it must be paid at time of service.


What is a deductible?

Your health plan may have a yearly amount that you must pay before insurance pays out for doctor visit. We do not bill for deductibe and it must be paid at time of service.


How frequent are office visits?

Due to federal regulations, patients receiving controlled drugs are generally seen once a month. All other patient visits vary based on their treatment plan.

Why did I receive a bill?

After insurance settles payment on claim, any portion of bill not paid and assigned to patient or any uncovered services are billed to beneficiary of services.

Can I see the doctor on the evenings or weekends?

Evening or weekend emergency care can be received at local ER or Urgent Care Centers.

Why do I have to wait for a MRI or Injection Procedure? Why can't I have it today?

Your insurance company has to generally approve any MRI or pain procedures before they can be scheduled. Please allow time for authorization from Insurance.

How can I see my MRI?

Generally with in 24 hours we are able to review your MRI images on computer. As you finish taking MRI, call us and schedule an in-office review of images  with physician or if you desire, we will mail your report at your request


What is your privacy policy?

We do not release any part of your medical records to a third party without your written authorization. Detailed HIPPA document will be available for your review at initial visit to our office.

What is your healthy back program?

We focus on an integrated approach for  patients with chronic back pain. The program requires:

• Lifestyle modifications

• Nutrition management for weight loss

• Routine exercise program (including stretching, strengthening and core building) 

• Posture control

• Smoking cessation

• Stress and sleep management

• Treatment of emotional issues



What Insurance Plans do you accept?

We accept following Insurance plans:

• Self pay for uninsured or out of network

• Aetna

• Blue Cross Blue Shield (out of network care available)

• Cigna

• Coventary

• Humana

• Medicare

• Peoples Health

• United Health Care

• Workman's Comp Injury (with authorization number only)

• Tricare

• Veteran Administration

All HMO plans may require written referral with authorization number

What if I run out of medications at night or on weekends?

Unfortunately , our office is not physically staffed in evenings and weekends . All pharmacy requests received after work hours will remain pending until next working day.

What is your policy on controlled drugs?

LONG TERM OPIOID USE CONTRACT:  We recommend that you sign contract If you are diagnosed with a medical condition requiring long term use of Opioids or if you are  being treated for drug addiction. Copy of contract will be provided to you and it outlines the policies related to the controlled drug prescriptions at our clinic.

Additional Notes

• Please avoid phone calls to request refill on narcotics. Due to federal regulations, refill requests for controlled drugs are accepted only during office visits.

• Due to high risk of diversion, misrepresentation and misuse, we are unable to accept requests for replacing lost or misplaced prescription of narcotics.

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