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176 Falls Ave, Twin Falls, ID 83301
EXPRESS PAY
SOUTHERN IDAHO
PAIN INSTITUTE
Home
Treatments
Back Pain
Neck Pain
Knee Pain
Migraines
Pain Management
Platelet-Rich Plasma (PRP) Injections
Trigger Point Injections
Conditions Treated
Meet The Doctors
Contact Us
Videos
Patients
Patient Forms
Patient Portal
Advanced Directive
No Show Policy
Home
Treatments
Back Pain
Neck Pain
Knee Pain
Migraines
Pain Management
Platelet-Rich Plasma (PRP) Injections
Trigger Point Injections
Conditions Treated
Meet The Doctors
Contact Us
Videos
Patients
Patient Forms
Patient Portal
Advanced Directive
No Show Policy
CALL FOR APPOINTMENT
Demographics Form
Specialists & Anesthesiologist in Twin Falls
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Authorization to leave information on voicemail or answering machine
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Medical Information
Is your visit Accident Related?
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Do you have a medical power of attorney:
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If yes, who?
Do you have an Advanced Directive:
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If yes, Do you have an Attorney?
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If you have an attorney, who is your attorney?
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Who was your employer at the time of your Work Related Accident?
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Today I will be paying by
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I hereby authorize the physicians of this office and their designates to provide medical treatment release of information pertaining to my treatment for insurances purposes. I understand that I am financially responsible for all professional services rendered. I authorize the insurance company to pay benefits directly to the physician. I understand that I am responsible to supply all necessary information, such as insurance information, authorizations, and referrals, so that my insurance can be properly filed. I further agree to pay all collections costs, reasonable attorney fees, and other collections costs that may be incurred to enforce collection of any amounts outstanding.
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