New Patient Information & Medical Record Release Form

New Patient Information & Medical Record Release Form
Name

First NameMiddle NameLast Name
Date of Birth (mm-dd-yyyy) - Must be 18 or older
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Cell or Home?
E-mail
I understand Dr. Fussell is an interventional pain physician who does injections for pain and is not likely to prescribe narcotics or opioids such as hydrocodone, oxycodone, or Percocet.
What kind of pain are you experiencing? (e.g. low back, neck, knee, sciatica, etc.)
For the pain mentioned above, I have had (check any that apply)
If you had an MRI or CT scan, where did you have it done (e.g. Phoebe, American Health Imaging, Tifton Open MRI, etc)?
If you had Physical Therapy, where did you have it done (e.g. Phoebe, Fyzical, Benchmark, etc)
Insurance Questions
1. What is the name of your PRIMARY Insurance?
Please provide the member ID or subscriber ID
Is your Primary Insurance an HMO?
2. What is the name of your SECONDARY Insurance?
Please provide the member ID or subscriber ID
3. If you have a DSNP insurance, please provide your Medicaid number here (blue card)
Medical Record Release
Who is your primary care doctor or facility?
If applicable, what specialist or facility are have you seen?
If applicable, who was your previous pain management doctor or facility?
I give Interventional Pain Institute/Dr. Fussell's office permission to obtain the following medical records from any/all providers mentioned in this document. I understand I have the right to revoke this authorization in writing at anytime. (check all that apply)
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Once medical records have been received, our office will contact you to make a new patient appointment.
Send/Fax Medical Records to:

Interventional Pain Institute / Dr. Fussell, 3200 Gillionville Rd, Albany GA 31721 or FAX 229-405-2473. If you have questions contact the office at 229-405-2470
Should be Empty:

New Patient Information & Medical Record Release Form

Insurance Questions

Medical Record Release

Send/Fax Medical Records to: