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Kentucky Pain Associates

Kentucky Pain Associates specializes in pain management and after auto injury care. We accept referrals from attorneys and chiropractors. Find out how we can help with your next case.

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Self Referrals

Patient Demographic Form

Referred From
Your Name*
Your Email*
TREATMENTS, SERVICES REQUESTED
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- Pain Management
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- Medication Management (Meds, TPI, DME)
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- Interventional Pain Management
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- Injections, Epidurals, Radiofrequency Ablation, etc. (Spine, Neck)
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- Joint Injections (Extremities)
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- TBI Evaluation Only (to determine if TBI testing is needed)
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- Objective TBI Evaluation
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- NeuroPsych TBI Evaluation
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- PTSD Evaluation Only (to determine if PTSD testing is needed)
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- TBI & PTSD Evaluation Only
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- Pain Management and
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- Objective TBI Evaluation
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- NeuroPsych TBI Evaluation
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- PTSD Evaluation
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- Surgical Consultation
Injury/Illness is due to*
- Auto Accident
- Work Related (Worker's Comp)
- Chronic Pain
- Slip and Fall
If it was an auto accident, describe the vehicle type.
- Owned/Leased
- Rental Car
- TARC
- Taxi/Uber/Lyft
Date of Accident Causing Injury*
MM slash DD slash YYYY
Name*
First Middle Last
Address*
Street Address Address Line 2 City State Zip
Closest Location Preferred*
Date of Birth*
Age*
Please enter a number from 0 to 99.
Is the patient a minor?*
- Yes
- No
Gender*
- Male
- Female
Marital Status*
- Single
- Married
- Divorced
- Widowed
- Separated
Social Security Number*
Primary Phone Number*
Cell Phone
Email*
Attorney Name*
Attorney Phone Number:*
Name of Insurance Company:*
Insurance Company Phone Number:*
Claim Number:*
PIP Balance
State where the accident occured*
Was the vehicle a Rental Car*
- Yes
- No
Do you own a vehicle?*
- Yes
- No
Patient Resides With*
- Alone
- Spouse
- Parents
- Children
- Other
Do any household family members own a vehicle*
- Yes
- No
How did you hear about us?
Please enter the name of the Medical Office and Provider*
Please enter the name of the ER and Provider:*
Additional Comments
The need for diagnostic testing and/or procedure has been thoroughly explained to me and I agree to have the testing performed in this office. I further understand my treating physician will arrange an acceptable payment plan for any cost not covered by my insurance. PLEASE PRESENT INSURANCE CARDS AND PHOTO ID TO THE RECEPTIONIST SO COPIES MAY BE MADE.
Patient or Responsible Party Signature*
- I Agree (Terms and Conditions following)
Date*
MM slash DD slash YYYY
I authorize the doctor and other health-care professionals (clinical staff) to perform diagnostic procedures and treatment as may be necessary for proper medical care. I authorize Kentucky Pain Associates to release any medical information including the diagnosis and the records of any treatment or examination rendered to me/my child during the period of such care to third party payers, and other entities and/or health practitioners. I authorize and assign directly to Kentucky Pain Associates all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.
Patient or Responsible Party Signature*
- I Agree (Terms and Conditions following)
Date*
MM slash DD slash YYYY
In order to help us stay within the guidelines of HIPAA, please list any person(s) that you authorize us to speak with about your medical condition. You do not need to list any of your physicians.
Name
Relationship
Name
Relationship
Name
Relationship
Do we have your permission to leave messages regarding information (such as appointment reminders or requests to call the office) when you are not at home?*
- Yes
- No
Do we have your permission to call you at the listed secondary phone number?*
- Yes
- No
Do we have your permission to email you with important information and/or periodic updates?*
- Yes
- No
We respect your privacy and will never share it with anyone.
By signing below you agree that you have read the HIPAA guidelines posted in the office. If you would like a copy of the guidelines one will be provided to you.
Patient Name*
Patient Signature*
- I agree
Today's Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.