Patient Forms

Forms for your convenience:

• Referral Form
• Accident Referral Form
• Request Records Sent to PCWFL
• Request Records From PCWFL
• Patient Financial Obligation
• Notice of Pricing for Medical Records
• Notice of Nondiscrimination
• Notice of Privacy Policy
• Website Privacy Policy
• Pain Management Agreement
• Nonopiod Alternatives for the Treatment of Pain

Procedure Information

• Hip Joint Injection Information
• Transcutaneous Electrical Nerve Stimulation
• Sympathetic Block Information
• Platelet Rich Plasma Patient Info
• Caudal Epidural Injection Information
• Cervical Thoracic and Lumbar Discography Information
• Cervical Thoracic and Lumbar Facet Joint Injection Information
• Cervical Thoracic and Lumbar Interlaminar Epidural Injection Information
• Cervical Thoracic and Lumbosacral Medial Branch Block Information
• Cervical Thoracic and Lumbosacral Spinal Nerve Injection Diagnostic Transforaminal Injection
• Costotransverse and Costovertebral Joint Injection Information
• Radiofrequency Neurotomy Information for Facet Joint Pain
• Radiofrequency Neurotomy Information for Sacroiliac Joint Pain
• Sacroiliac Joint Injection Information
• Spinal Pain
• Transforaminal Epidural

The following protocols help our practice stay as efficient and effective as possible.

• PCWFL is an interventional procedure-oriented practice that employs various pharmaceutical agents in conjunction with procedures and physical therapy. PCWFL considers any opioid agent to be a last line therapy as its health risks mandate that it be prescribed at the lowest possible dose for the shortest time period.  Please review our pain management agreement for a full understanding of your responsibilities to the policies of this agreement, which provides for your safety and the safety of the public.
• PCWFL reserves the right to NOT prescribe medications for a new patient, until all applicable drug screening has been performed, processed by the lab and the results have been reviewed by the physician. At that time a determination can be made if prescriptions will be written by PCWFL
• As part of our contract with the insurance companies we are legally required by the terms of the contract to collect any co-pays or deductibles from you at the time of service. We do ask that you be prepared to pay your co-pay at the time of check in. Patients who do not have insurance coverage will be expected to pay at the time of service. A $200 deposit will be collected before seeing the physician. For your convenience we accept Cash, Check, MasterCard and Visa.
• You will be required to have a valid photo I.D. at your appointments. Your insurance card, if applicable, will also need to be present for your appointments.
• You will receive an email 3 days prior to your appointment that will contain all of your new patient paperwork. Completing this paperwork ahead of time will allow us to expedite your appointment. However, you have the option to complete the paperwork in our office, on one of our Phreesia tablets when you arrive.
• PCWFL Late Patient Policy: We require that New Patients arrive to their first appointment at least 45 minutes before the scheduled appointment time, to allow ample time to complete any paperwork and insurance information. For all procedures, patients should arrive 45 minutes before the scheduled appointment time to complete the pre-operative process. PCWFL reserves the right to reschedule any patient who does not arrive within these timeframes. A no show fee will be charged for missing the appointment