Forms

Denver Back Pain Specialists welcomes you to our practice!

Dear New Patient

Please complete these forms before your first visit:

Patient Information Form 9.25.12

Spine Health History 11.17.14

Payment Policy_10.6.12

Privacy Policy_04.25.14

Online Communications Informed Consent_9.28.12

Confidential Communications Request 4.25.14

Medical Release Form 10.6.12

In some cases, you may also be asked to fill out these function related questionnaires:

Modified Oswestry Low Back Disability Index

Modified Oswestry Neck Disability Index

For referrals to Physical Therapy:

Physical Therapy Referral: Denver Back Pain Specialists

For referrals to Dr. Bainbridge and Dr. Shoemaker:

Referral Form: Dr. Bainbridge Denver Back Pain Specialists

Additional Practice Information and Disclosures:

Dr. Bainbridge and Associates Hospital Affiliations 11.30.13

Notice of Physician Business Relationships 6.11.16

Injection Information and Forms

 We accept, and are “in-network” with, the following insurances:

Aetna

Ameriben

Auto

Beech Street

BCBS

Cigna/Great West

CNIC

Cofinity

Cover Colorado/Rocky Mountain Health Plans

First Health

GEHA

Golden Rule

Humana

Medicare

Pinnacol (SelectNet)

San Luis Valley

Unicare

United Healthcare

Secure Horizons

Tricare ( not prime )

Work Comp