You can save these forms on your computer and fill them out using the Adobe Acrobat Reader — then email them to firstname.lastname@example.org. Or, you can print the forms, fill them out and bring them to your appointment.
Medical and Authorization Forms:
- Registration Form
- Medical History
- Patient Consent for Use and Disclosures
- Medications and Allergies
- Medical Records Request Form
- Authorization for Assignment of Benefits Form
- Maryland Brain, Spine + Pain Lien (for those injured at work or in a car accident) – This is needed if your insurance company requires one. If your visit is related to a work or auto accident, you must provide us with the name of the work or auto insurance carrier, address to send claim to, claim #, date of injury, name and telephone # of the claim adjuster, and the name and number of attorney if you have one.
For Physician Use: