Bend Spine &
Pain Specialists

929 SW Simpson Ave.
Suite 250
Bend, OR 97702

Additional
Information

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Chronic
Neuropathic Pain

Narcotic
Pain Medications

Radiofrequency
Ablation

Patient Forms
Please download the following forms and fill them out completely and accurately prior to your appointment. Along with this paperwork please follow these instructions on how to prepare for your first appointment:

• Check with your insurance plan to verify coverage and benefits.
• Make sure we have received previous records related to the pain complaint.
• Let us know if you have had any diagnostic imaging (X-ray, MRI, etc.).
• Plan to arrive 15 minutes early with all the required paperwork completed.
• Bring all of your medications in the original bottles.
• Bring a copy of your insurance card, co-pay or deposit if necessary.

New Patient Letter

Health Questionnaire

Health Questionnaire for New Fibromyalgia Patients

Patient Information Form with Consents and Releases

Release of Records Authorization Form

Referral Form (for referring providers only)

Injection Pre-Procedure Instructions

Injection Post-Procedure Instructions

Information for Patients on Narcotics

The Health Insurance Portability and Accountability Act of 1996 (HIPAA), protects health information created or maintained by health care providers throughout the United States.
Also as part of the HIPAA regulations, each patient has the right, with some restrictions, to:

• Review his or her own medical record;
• Request an amendment or correction to the medical record;
• Add supplemental information to the record;
• Restrict use and disclosure of your medical information;
• Authorize formal consent before health information is released other than for treatment, payment or as part of health care operations and
• Know who requested and received medical information for reasons other than treatment, payment, or health care operations.

This notice describes in detail how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. You will be asked to acknowledge that you have received a Notice of Privacy Practices prior to receiving care at Bend Spine and Pain Specialists.

Notice of Privacy Practices
   


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