Patient Forms

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

Please bring the following when you visit Southeastern Spine and Joint for your first appointment:

• Completed New Patient Information Form and additional paperwork from the list below
  • New Patient Information Form – Lumbar Spine
  • New Patient Information Form – Cervical Spine
  • New Patient Information Form – Hip
  • New Patient Information Form – Knees
  • Authorization for Release of PHI - HIPAA Release Form
• Your Insurance Card
• Co-payment (if required by insurance). We accept cash, major credit cards or personal check.
• Referral paperwork (if required by your insurance).
• Medical records and imaging reports, x-rays, and/or disc with imaging pertaining to your treatment from other health care providers (if you have them).

New Patient Filing Workers Comp or Auto Accident Forms:

• Injury Patient Information Form

Additional Health Information:

• Pre-Surgery Questionnaire

Please review these important 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
• English Right to a GFE Notice
• Spanish Right to a GFE Notice

Insurances Accepted:

• Payer Participation List

Records Requests:

• For medical records requests please email records@southeasternspine.net

Southeastern Spine and Joint will provide a thorough evaluation based on your symptoms, conditions and medical history. Bringing this information to your first appointment ensures that we can provide the best possible service during your first consultation.