In order to save you time, please print out and fill out all the appropriate forms before coming to the office. Feel free to call us with any questions that you may have. Having the forms ready when you come to the office will enable us to keep our appointment schedules and minimize your time away from your home or work. Please read the lists below carefully to accurately categorize yourself. If you need any help, please contact the office at 615-451575.
Private Pay Patients or Patients without Insurance
If you prefer private payment without insurance, please fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Pain Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Pain Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.
Group or Individual Insurance (Most Insurances accepted)
If you have any type of insurance that you wish us to file on your behalf, please fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Pain Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Pain Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.
SECONDARY INSURANCE - Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.
United Health Care Insurance
If you have United Healthcare insurance you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Pain Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Pain Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.
Medicare Insurance Forms
If you have Medicare insurance, please fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Pain Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Pain Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.
Personal Injury Forms
If you have been injured by an accident, other than an Occupational or Motor Vehicle accident, you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Pain Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Pain Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.
Motor Vehicle Accident Forms
If you have been injured in a Motor Vehicle Accident or have been involved in an auto accident, you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Pain Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Pain Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.
Occupational Injury Forms
If you have been injured on the job or if your injury is a result of your occupation, you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Pain Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Pain Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.
Massage /Reflexology Intake Form
If you are interested in using our Massage Therapy/Reflexology services to relax and rejuvenate, please fill out this form.
Personal Training Form
If you are interested in utilizing one of our personal trainers to help you during your exercise regimen, please fill out this form.
Returning Patients
Please fill out the category of forms above that best pertains to you.
Hippa Policy and Procedures
The purpose of this form is to inform you of your rights and privileges as a patient and to fully disclose our policies with regards to distribution of your patient information. You will receive a copy of this form upon entry as a patient or you may pick up a copy of this form during regular office hours.