New Patient Candidacy Form

New Patient Candidacy Form
PEACHTREE CORNERS LOCATION

5246 Peachtree Pkwy, Peachtree Corners GA 30092-2234
Personal Information
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Gender*
E-mail*
Primary Care Provider
Primary Care Provider Phone Number
Financial Information

Note: We Do Not Accept Medicaid.
Name of Medical Insurance:*
Type None if you don't have insurance
Type of Insurance:
PPO, POC, HMO etc.
Are you selfpaid?

YesNo
Appointment Details
The Chief Complaint of Pain:*
Example: Low Back Pain
Are you experiencing any of the following? (Please check all that apply)*

Neck PainShoulder PainHip PainMid Back PainElbow PainKnee PainLow Back painWrist PainAnkle painButtock PainHand PainAbdominal PainHeadacheMigraineFacial PainNo Other PainCancer PainDiffuse BodyacheOther
Is this appointment related to work or auto injury?*

YesNo
Are you transferring from another pain clinic?*

YesNo
Reason for transferring from previous pain clinic?*
Type N/A if not applicable
Name of last Pain Clinic or Doctor:*
Type N/A if not applicable
Are you on Pain Medications?*

YesNo
What pain medications or drugs are you taking?*
Example: Hydrocodone, Oxycodone etc.
Have you had recent MRI/X-Rays of Back or Joints?*

YesNo
Where MRI was performed?
Name of the Facility
Do you have report of MRI?
Please bring report with you
Any previous back surgery?*

YesNo
Describe your surgery:
Any spine or joint injections previously?*

YesNo
What kind of injections? (Please check all that apply)*

Epidural InjectionHip InjectionHand InjectionFacet InjectionKnee InjectionElbow InjectionSIJ InjectionAnkle injectionShoulder Inj.Nerve BlocksTrigger PointsNo InjectionsOther
Would you like to get injections to better manage your pain?*

YesNo
Do you require assistance with walking?*

Walk without assistanceWheelchairScooterWalkerCrutchesCaneOther
Do you work?*

YesNo
Are you on disability?*

YesNo
Are you planning to apply for disability?*

YesNo
List any other health problems, no matter how insignificant they may be:
Upload a Copy of Driver License and Both Sides of Medical Insurance Card.*

Browse Files
Scan or Take a Picture of License and Card with your Phone and upload here. Cancelof
UPLOAD A HEAD-SHOT FOR YOUR PROFILE

Browse Files
Take a Head-shot with your phone and upload here Cancelof
The Privacy Regulations (HIPAA)
The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require the ethical and legal commitment to the confidentiality of your Personal Health Information.
Under the laws of the United States and the state of Georgia, your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.
Use and Disclosure of your Personal Health Information (PHI)
Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

 Health Care Provider - PHI may be used and disclosed to your physician or other healthcare provider who is also treating you.

 Payment - Your PHI may be used and disclosed to your health plan or other third party for payment of services provided for you. If your contract with your insurance company requires that information relevant to the services provided be given before payment, providing them with a clinical diagnosis, as well as clinical information such as treatment plans or summaries and/or copies of any records maintained about your therapy sessions may be required.

 Health Care Operations - Your PHI may be used and disclosed to staff members for the purpose of obtaining insurance eligibility, billing health insurance and inquiring about claim status.

 As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program.

 Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law.

 Appointment Reminders - You may be contacted by phone or email for an appointment reminder. If contact is by phone, a recorded message may be left on your answering machine.

Appointment Cancellation – If for some reason an appointment must be canceled, you will be contacted by phone or email. If contact is by phone, a recorded message may be left on your answering machine/voicemail.

 Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed.

 Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed.
Communication
We are committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website; you can be assured that it will only be used in accordance with this privacy statement.

We will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the contents of your email will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.
Signature and Submission
Please type your name below to indicate consent to treatment.
Patient's Signature*
Type your full name
eSignature*

Clear
Use your finger on touch screen or mouse on non-touch screen
Date*

MonthDayYear
If the patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature
Date

MonthDayYear
Should be Empty:

New Patient Candidacy Form

Personal Information

Financial Information

Appointment Details

The Privacy Regulations (HIPAA)

Use and Disclosure of your Personal Health Information (PHI)

Communication

Signature and Submission