PainPA, LLC - Publicforms

Available Forms

1. NEW PATIENT REGISTRATION ALL MUST COMPLETE 2. HIPAA, TELEMEDICINE, NON-DISCLOSURE AGREEMENT & BILLING POLICIES 3. MEDICAL QUESTIONNAIRE ALL MUST COMPLETE 4. PAIN ASSESSMENT FORM ONLY COMPLETE IF APPLICABLE MEDICAL MARIJUANA CONSENT ONLY COMPLETE IF APPLICABLE NARCOTIC PRESCRIBING AGREEMENT ONLY DO IF APPLICABLE QUICK CONTACT US RECORD RELEASE FORM SUBOXONE INTAKE QUESTIONNAIRE ONLY COMPLETE IF APPLICABLE SUBOXONE OR BUPRENORPHINE CONSENT FOR TREATMENT & RELEASE OF INFORMATION ONLY COMPLETE IF APPLICABLE

1. NEW PATIENT REGISTRATION ALL MUST COMPLETE

FIRST NAME *

MIDDLE INITIAL *

IF NONE WRITE NA

LAST NAME *

REASON FOR TREATMENT *

PAIN TREATMENT

MEDICAL MARIJUANA CARD

REGENERATIVE PROCEDURES

OPIOID USE DISORDER TREATMENT

SUBOXONE OR SIMILAR

KETAMINE INFUSIONS

PLEASE SELECT ALL THAT APPLY

Date of birth *

Please enter month/day/year EXAMPLE GIVEN 01/08/1945

What is your gender? *

The practice does not discriminate on the basis of gender identity or expression.

Address *

Street address

City *

State *

Zip *

Cell phone # *

If you don't have one write none

Home phone # *

If you don't have one write none

E-mail address *

Race

Optional: We do not discriminate based upon race, color or creed

Ethnicity

African-American

Asian

German-American

Hispanic-Latino

Italian-American

Irish-American

Jewish-American

Other

OPTIONAL MY PRACTICE DOES NOT DISCRIMINATE BASED UPON ETHNICITY

Preferred Language

Marital Status *

Maiden name or alias *

If none please indicate none

Social Security Number *

Who referred you? *

Primary Care Physician

Doctor's Name: *

Office Phone Number: *

Fax Number:

if known

Location (city, state): *

Insurance

Primary Insurance *

Commercial - Blue Shield

MEDICARE

TRICARE

Workers Compensation

Automotive

Self Pay

Other

Primary Insurance Company Name *

Enter name of insurance carrier, If self pay please write "none"

Claims Address

Ignore if Medicare as we send it electronically. Otherwise put the claims address listed on the card here, unless self pay - in which case skip

Customer Service Phone #

If Medicare leave blank, if self pay leave blank, otherwise enter the number for "Providers or Physicians or Hospitals" listed on the card or letter from WC or Auto Carrier

Policy holder name

If not yourself

Policy holder's date of birth

If not yourself

Policy Number *

Type claim number if W/C or auto, or new Medicare ID#. None if self pay.

Group #

Date of injury or accident

For workers comp and auto

Adjuster's name and contact info

Only fill out if you have a workers compensation or auto injury claim<br/>Name, address, phone number, fax number

SECONDARY INSURANCE

If you have a secondary insurance, please enter name of carrier, policy holder with date of birth if not you, the policy number, group number, claims address.

EMERGENCY CONTACT

PRIMARY EMERGENCY CONTACT *

PLEASE LIST NAME, RELATIONSHIP,<br/>ADDRESS AND CELL AND HOME PHONE NUMBER

SECOND EMERGENCY CONTACT *

NOTE MUST NOT LIVE WITH YOU<br/>PLEASE GIVE NAME, RELATIONSHIP, ADDRESS, HOME AND CELL NUMBERS

SIGNATURE *

PLEASE ENTER FULL NAME

WARNING: YOU MUST CLICK "SUBMIT FORM" BELOW AND SEE A MESSAGE IN GREEN STATING "SUCCESSFULLY SUBMITTED" BEFORE GOING TO THE NEXT FORM OR THE ENTIRE FORM WILL BE LOST

* Required field