Patient Forms

Prior to your first appointment, you will be asked to review and sign some of these forms as part of our electronic intake process. Signed forms can then be printed from the patient portal. You can also review and print unsigned forms below.

Patient Forms

Prior to your first appointment, you will be asked to review and sign some of these forms as part of our electronic intake process.  Signed forms can then be printed from the patient portal. You can also review and print unsigned forms below.

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Office Policies 

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Politica Financiera

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de Practicas de Privacidad

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Pain Management Specialists Office and Surgery Center Policies (PDF) - This document includes notices and policies concerning missed appointments, prescription refills, billing, surgery center ownership, closure for inclement weather, etc. Políticas de consultorios y centros de cirugía