Patients

Below, you’ll find our most-requested patient forms at Southeastern Spine and Neurosurgery. Please print and fill out the forms that apply to your situation before your first visit at Southeastern Spine and Neurosurgery.

• New Patient Information Form – Lumbar Spine
• New Patient Information Form – Cervical Spine

New Patients Filing Health Insurance Forms:

• Patient Health Insurance Information Form
• Patient HIPAA Disclosure Release Form
• Records Release Authorization
• New Patient Oswestry Questionnaire
• New Patient Medical History Questionnaire

New Patient Filing Workers Comp or Auto Accident Forms:

• Injury Patient Information Form
• Auto Accident Attorney Letter of Protection
• Patient HIPAA Disclosure Release Form
• Records Release Authorization Form
• Personal Injury Insurance Filing Selection Notice
• New Patient Oswestry Questionnaire
• New Patient Medical History Questionnaire

Notices

• HIPAA Notice – This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
• Nondiscrimination Statement

Insurances Accepted

• Payer Participation List