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4701 Bluebonnet Blvd
Suite B
Baton Rouge, LA 70809
(225) 291-2626
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New Patient Information Forms
I hope that visiting this website has been the beginning of a positive experience for you at our office.
We want your first visit to our office to be as easy and efficient as possible. One of the ways we get to know about you and your health, as well as to better communicate with your primary physician and insurance company is from information that you provide on paper.
To this end, the following forms may be downloaded and completed at your convenience
before your appointment. We will add them to the information the doctor will review on your
first visit. Doing this ahead of time will decrease the time you spend completing paperwork,
so more time can be spent with the doctor.
1. Please select the forms package that best describes your situation:
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Commercial Health Insurance Forms if we will be billing your BC/BS, Humana, State Group, Aetna, Cigna or other health insurance (except UnitedHealthCare and Medicare, please see below)
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United Health Care Forms
UnitedHealthCare requires additional forms to be completed by the patient.
For a neck complaint, complete the Patient Summary and the Neck Index
For a back complaint, complete the Patient Summary, Back Index and Lower Extremity Functional Scale
For an Arm, Shoulder and Hand complaint, complete the Patient Summary. Neck Index and DASH
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Medicare Registration Forms if you are a Medicare recipient
Important information for our Medicare Patients
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Personal Injury Insurance Forms if you were involved in a motor vehicle accident
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If you were involved in a work related injury, please contact our office for the appropiate forms.
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Private Pay Registration Forms if you do not have insurance coverage and will be paying privately for your care
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2. To help us evaluate your progress, please select the correct set of questionnaires below which will provide us your baseline level of pain and function loss.
Experiencing neck pain? Please download and complete the following.
Neck Disability Index (Vernon-Meyer)
Experiencing low back pain? Please download and complete the following.
Low Back Disability Index (Oswestry)
If you should have any questions about these forms, please feel free to contact me, Dr. Smith at rsmith@spinesmith.com.
If you have questions concerning your insurance plan and whether we are providers for that plan, please contact our office at 225.291.2626 or the Insurance Information page. |
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