• Home
  • About Us
  • Services
  • Veterans
  • Contact Us
  • Acupuncture
  • Reviews
  • Blog
  • Massage Therapy
  • Paperwork & Forms
  • Fun Photos
  • Weight Management
  • Info on Delta 8 THC & CBD
  • Shop Our Store
  • Prolotherapy & Prolozone
  • Product Recommendations
  • More
    • Home
    • About Us
    • Services
    • Veterans
    • Contact Us
    • Acupuncture
    • Reviews
    • Blog
    • Massage Therapy
    • Paperwork & Forms
    • Fun Photos
    • Weight Management
    • Info on Delta 8 THC & CBD
    • Shop Our Store
    • Prolotherapy & Prolozone
    • Product Recommendations

  • Home
  • About Us
  • Services
  • Veterans
  • Contact Us
  • Acupuncture
  • Reviews
  • Blog
  • Massage Therapy
  • Paperwork & Forms
  • Fun Photos
  • Weight Management
  • Info on Delta 8 THC & CBD
  • Shop Our Store
  • Prolotherapy & Prolozone
  • Product Recommendations

No printer? No problem! Submit 100% online

Veterans referred by the VA must also submit a Military History Form

Simply click on the links below:

New Patient Paperwork

Military History Form


To download and print paperwork please scroll down and select from files below.


DOWNLOAD and print paperwork

New Patient Packets

VA NEW PATIENT PAPERWORK (pdf)

Download

VA NEW PATIENT PAPERWORK Word Document (docx)

Download

NON-VETERAN NEW PATIENT PAPERWORK (pdf)

Download

NON-VETERAN NEW PATIENT PAPERWORK (docx)

Download

ELA HIPAA NOTICE OF PRIVACY REV. 11.11.19 (pdf)

Download

RECORDS RELEASE FORMS

Records Requests and Release Forms

HIPAA release to share info with family or friends (pdf)

Download

HIPAA RELEASE TO OTHER DOCTORS OR LAWYERS (pdf)

Download

INSURANCE BILLING-RELATED FORMS

Insurance Billing Forms

Medicare Form 1490-S To Obtain Medicare Denial Letter - SPANISH (pdf)

Download

Medicare Form 1490-S To Obtain Medicare Denial Letter - ENGLISH (pdf)

Download

Out-of-Network Notice (docx)

Download

Aetna - Medicare Medical Claim Reimbursement Instructions (pdf)

Download

Network Gap Exceptions Can Help Get the Care You Need (pdf)

Download

Misc. forms

Fee schedule and other misc. forms

2021 - 2022 Fee Schedule (docx)

Download

129 East 13th Street. St. Cloud, FL 34769  Ph: 407-738-7412

Powered by

  • Services
  • Veterans
  • Acupuncture
  • Reviews
  • Massage Therapy
  • Paperwork & Forms
  • Privacy Policy & Terms
  • Weight Management
  • Shop Our Store
  • Product Recommendations

Cookie Policy

This website uses cookies. By continuing to use this site, you accept our use of cookies.

DeclineAccept & Close