Medical Forms

MEDICAL FORMS

Authorization for Use and Disclosure of PHI

This form is so any other providers you have seen can send your records to us so we can have a complete medical history.  Jacksonville Spine Center will also use this form to release or send your medical records to another provider on your behalf. Please fill out the form completely, sign it, and date it.

 

Notice of Privacy Practices

This notice describes how information about you may be used and disclosed and how you can get access to this information.  Please review it, fill out the brief form, sign it, and date it.

 

New Patient Packet

This is a very important packet.  These forms provide us with your contact information, insurance, whether your injury is a result of a workman’s comp incident or auto accident.  It also requests details about your pain, existing/previous medical conditions and what medications you are currently taking.  It is a very comprehensive document and you will save a great deal of time in the waiting room if you fill this out prior to your appointment.  

 

For your convenience, here is a list of the insurance we accept: 



Aetna

Auto/PIP/Med Pay

AvMed

Blue Cross Blue Shield

Cigna

Department of Labor

GEHA
Health Net

Humana

Medicare

Tricare

United Health Care

WellCare

Worker’s Compensation

Most Commercial Carriers