Regional Spine Specialists

Available Forms

Intake Registration

Registration

Today's Date *

Salutation

Marital Status *

First Name *

Middle Initial

Last Name *

Is This Your Legal Name?

If not, what is your legal name?

Former Name

Date of Birth *

Age *

Sex *

Street Address *

Social Security Number *

Home Phone Number

Cell Phone Number

Pharmacy Name/Phone No. *

Occupation

Employer

Employer Phone Number

Referred to Clinic By

Referring Provider's Name

Primary Care Physician *

Do You Have A Pain Doctor? *

Name of Pain Doctor

Email *

Person Responsible For Bill

Birth Date

Primary Insurance *

Policy Number *

Group Number

Patient's Relationship to Policy Holder *

Secondary Insurance

Policy Number

Patient's Relationship to Policy Holder

Emergency Contact *

Relationship to Patient *

Phone Number *

Release of Information

I authorize the physician to release/obtain medical information including information and records or copies of records relating to the history, diagnosis, treatment or services rendered to me in connection with any condition or disease as well as any information pertinent to assist in the filing of an insurance claim.

Notice of Privacy Practices

I acknowledge that by signing below, I have read (or can obtain a copy of upon request) the "Notice of Privacy Practices" policy and understand my medical information rights.

Assignment of Benefits

I assign all medical and surgical benefits to which I am entitled, to the physician. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid to the original.

Payment Responsibility

As a courtesy, Dr. Henrik Mike-Mayer, MD will file all claims with your insurance company. If payment has not been received within 45 days from the filing date, I understand that I am fully responsible for payment of all services rendered.

Missed Appointment Responsibility

I acknowledge that if I miss an appointment without providing the office 24 hours notice I am responsible for a $50 fee.

Billing And Insurance Policies

As a courtesy to our patient we will file your insurance forms from our office. In order to do this we will require information from you to assist us in the billing process. We ask that you provide our office with your insurance information as well as all correct demographic information. At the time of service you will be responsible for all fees, including co-pays, co-insurance, deductible and non-covered services received. Although we are contracted with several insurance companies, it is your responsibility to make sure that our physician is in network with your insurance plan. Please verify your plan benefits prior to your appointment to help make the process run as smoothly as possible. We will assist you in any way we can to help this process. As a courtesy, the office of Dr. Henrik Mike-Mayer, MD will file all claims with your insurance company. If payment has not been received within 45 days from the filing date, you understand that you are responsible for all services rendered. If you are a worker's compensation patient, you will need to provide all of your workers compensation information including your claim number, adjustor name and phone number, and date of injury so that we may verify your compensation claim.

Electronic Signature *

* Required field