Patient Forms

Patient Medical Records

You can stop by our office Monday-Friday to pick up the Disc between 09:00 am to 04:30 pm.

AIC Prep Instructions -

NOW OPEN 7AM – 5:30PM MON – FRI FOR ALL SERVICES BY APPOINTMENT ONLY

New Prep Instructions and Map (File size: 626,335 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

New Script Pad

AIC script 2018 (File size: 1,449,809 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

PRINT ABN FOR MEDICARE POLICIES

AIC ABN (File size: 332,226 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

PRINT IF YOU HAVE ANY INSURANCE BESIDES MEDICARE

MANAGED CARE WAIVER-revised 07 2015 (File size: 64,022 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

Dexa Form

DXA Patient Questionnaire - English (File size: 381,963 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

X-Ray Form

XRAY FORM 18 (File size: 227,645 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

CT/PET Form

CT Questionnaire 18 (File size: 228,314 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

Auto Accident/Slip and Fall Paperwork

PIP-PAPERWORK-WITH-MCW-AND-ABN (File size: 612,406 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

HIPPA (PRIVACY POLICY)

HIPAA AND AUTHORIZATION (File size: 134,121 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

MRI

MRI Form (File size: 95,430 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.