Print Health Profile Form

Print HIPAA Release of Information Form

Print Consent to Treat Form

Print All Three Above Forms

To help us stay on schedule and understand your health issues and the nature of your pain, bring these items to your first pain relief appointment:

• A completed copy of the YNC Health Profile form (required for all patients)
  
  
• A completed copy of the YNC HIPAA Release Authorization form (required for all patients)
  
  
• A completed copy of YNC HIPAA Privacy and Consent form (required only if you have never been a YNC patient or have not visited your YNC doctor within the past 12 months)
  
  
• All recent X-rays, MRIs, CT scans, and other images and associated reports that might be pertinent to your evaluation and treatment
  
  Please contact the facility where your imaging was performed and request physical or digital copies. For a direct transfer of records to us, provide the facility where your records reside
  with a signed HIPAA Release of Information form.
  
  
• Your workers compensation form, if your pain is the result of a work-related injury
  
  
• Your insurance Proof of Claim form, if your pain is the result of a motor vehicle accident and you have filed a claim with your insurance company

Click here to print this checklist for reference.