Patient Forms & Office Policies
ARIZONA PAIN & SPINE INSTITUTE Mesa Office: 2045 S. Vineyard Road Suite 131 Mesa, AZ 85210 Ph: (480) 986-7246 Fax: (480) 986-7252 ___________________ East Mesa Office: 10238 E. Hampton Ave Suite 205 East Mesa, AZ 85281 Ph:(480) 986-7246 Fax: (480) 986-7252		Click on a form to download Physician Forms • Interventional Pain Management Referral Form Patient Forms • New Patient Welcome Letter • Authorization to Release Healthcare Iinformation • Consent for chronic opioid therapy • Opioid Contract • Copy of Office Policies • Patients Rights & Responsibilities Statement • Pain Pre-procedure Medication Recommendations And Instructions • Postoperative Instructions If you have received anesthesia Notice of Privacy Practices Forms • Notice of Privacy Practices Office Policies In effort to make your visit with us as easy as possible we ask that you make note of the following office policies. We thank you in advance for your cooperation. • Please notify of us of any changes to the following at the time of your visit: Address Insurance Information Medical illness, injury, or surgery since your last visit Medications added or discontinued since the last visit • Please notify us of a cancellation at least 24 hours in advance. • Please allow 72 hours for prescription refill requests to be completed. • All co-pays and deductibles are due at the time of visit. • There will be a $25.00 returned check charge. • The following fees apply to all medical record copying: $15.00 Clerical fee for records on CD $15.00 Clerical fee & $.10 per page - shipping & handling for paper copy of record. Click here to download a copy of Office Policies PLEASE NOTE: WE ACCEPT MOST MAJOR INSURANCE COMPANIES. PLEASE CONTACT OUR OFFICE FOR MORE INFORMATION. Note: To view these forms you will need the free Adobe Acrobat Reader. If you don't have it, download it now.

Patient Forms & Office Policies

ARIZONA PAIN &
SPINE INSTITUTE

Mesa Office:
2045 S. Vineyard Road
Suite 131
Mesa, AZ 85210

Ph: (480) 986-7246
Fax: (480) 986-7252
___________________

East Mesa Office:
10238 E. Hampton Ave
Suite 205
East Mesa, AZ 85281

Ph:(480) 986-7246
Fax: (480) 986-7252

Click on a form to download

Physician Forms
• Interventional Pain Management Referral Form

Patient Forms
• New Patient Welcome Letter
• Authorization to Release Healthcare Iinformation
• Consent for chronic opioid therapy
• Opioid Contract
• Copy of Office Policies
• Patients Rights & Responsibilities Statement
• Pain Pre-procedure Medication Recommendations And Instructions
• Postoperative Instructions If you have received anesthesia

Notice of Privacy Practices Forms
• Notice of Privacy Practices

Office Policies
In effort to make your visit with us as easy as possible we ask that you make note of the following office policies. We thank you in advance for your cooperation.

• Please notify of us of any changes to the following at the time of your visit:

Address
Insurance Information
Medical illness, injury, or surgery since your last visit
Medications added or discontinued since the last visit

• Please notify us of a cancellation at least 24 hours in advance.
• Please allow 72 hours for prescription refill requests to be completed.
• All co-pays and deductibles are due at the time of visit.
• There will be a $25.00 returned check charge.

• The following fees apply to all medical record copying:
$15.00 Clerical fee for records on CD
$15.00 Clerical fee & $.10 per page - shipping & handling for paper copy of record.

Click here to download a copy of Office Policies

PLEASE NOTE:
WE ACCEPT MOST MAJOR INSURANCE COMPANIES.
PLEASE CONTACT OUR OFFICE FOR MORE INFORMATION.

Note: To view these forms you will need the free Adobe Acrobat Reader.
If you don't have it, download it now.