New Patient Information & Forms


 

Thank you for entrusting your medical care to Headache & Pain Center, amc. We strive to make your visits comfortable with a minimal wait time. Please note that initial appointments may require additional time.

Please remember to bring your current insurance cards and a picture I.D. Please bring a list of your current medications. Prior diagnostic films, reports and medical records are also useful if they are available. For your convenience, it is recommended you click, print and complete the New Patient Forms from the link below. Completing these forms in advance and bringing them with you to your appointment will minimize your wait time.

We look forward to seeing you soon. Please do not hesitate to contact our office if you have any questions.

 

Patient Forms

Acknowledgment of Receipt of Notice of Privacy Practices

Download

 

Assignment of Benefits Form

Download

 

Assignment of Benefits Radiology (Gray)

Download

 

Assignment of Benefits Radiology (New Iberia)

Download

 

Disclosure of Ownership

Download

 

Notice of Privacy Practices

Download

 

Patient Intake Form

Download

 

Release of Medical Information to HPC (New Iberia)

Download

 

Communication Form

Download

 

Release of Medical Information to HPC (Gray)

Download

 

Patient Rights and Responsiblities

Download

 

Patients Demographic Information

Download

 

 

Download the New Patient Forms Packet

(This PDF file will open in a new browser window and provide 11 pages to fill out and bring with you to the Headache & Pain Center, amc)

About Care Credit


CareCredit health, wellness and beauty credit card

Whether it's a routine checkup or emergency surgery, you shouldn't have to worry about how to get the best medical care. That’s why we're pleased to accept the CareCredit healthcare credit card. CareCredit lets you say "yes" to recommend treatment and pay for it in convenient monthly payments that fit your budget.

CareCredit is the healthcare credit card designed exclusively for healthcare services with special financing options.* With CareCredit, you can use your card for all of your follow-up care as well as annual checkups.

Learn more by visiting www.carecredit.com or contacting our office. Ready to apply? Apply Online for your CareCredit card today.

*Subject to credit approval. Minimum monthly payments required. Ask us for details

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