Patient Forms

Preparing for Your Visit to New York Spine & Wellness Center

Thank you for selecting New York Spine & Wellness Center. For your convenience and to minimize wait times, we request that you complete the appropriate forms and bring them to your appointment.

New & Established Patient Forms

New Patient Packet
New EMG Patient Packet
Patient Payment Policy

Medical Records Release:

• Permission for Communicaiton
• Request to Obtain Copy of Records
• Permission of NYSWC to Obtain Records About You
• Permission to Release Records About You

3rd Party / Insurance Authorization Release and Forms:

• Appointment of Representative
• Release for PRIA: Mild Verification of Benefits and Authorization
• Release for SPRCARE (SPRINT PNS)
• Authorization to Release Records to New York State DFS for External Appeal