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
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 compete 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.