Resources

New Patient Information

Information needed to schedule an appointment
  • Patient’s First, Middle and Last Name
  • Address, City, State and Zip
  • Phone Number
  • Date of Birth
  • Photo ID (Driver’s License, or other government approved identification)
  • Type of insurance (commercial, Medicare, most Medicare replacement plans)
  • Self-pay (payment in full expected at time of visit)
  • Referral Order from Physician with the Reason for Referral
Medical Records Needed for First Appointment
  • Clinical Notes
  • Imaging and Imaging Reports (MRI’s, CT’s, X rays)
  • Past Surgical History Pertaining to Referral
  • Most Recent Lab Results
  • Recent Testing (EMG, NCV, EEG)
  • Recent Therapy Treatment (if any) (PT, OT)
Requirements for Each Visit
  • Co payments
  • Any outstanding financial balances must be paid at each visit
  • Insurance changes or updated insurance card and any demographic changes
Patient Forms

HIPAA Notice of Privacy Practices
Patient History Form
Medical Record Request & Release Form

Physician Referrals

We welcome the opportunity to partner with you on your patients who are looking to treat their pain. Midwest Pain & Spine serves as a resource for patients that require interventional spine management to treat their pain.

Click here to complete the Physician Referral Form and fax along with all pertinent medical information including past imaging and imaging reports, procedures, surgeries, physical therapy, recent testing, and other medical treatment to Fax: (317) 815-8951. For urgent requests, call (317) 815-8950, Ext. 1.

We are in-network with most commercial insurance plans, Medicare, and Medicare Replacement Plans.

After each visit, our medical team will provide you via fax with a detailed summary of care.