Patient Forms

New Patients

New Patient Paperwork

Authorization and Release Forms

Medical Records Release

• Permission for Communication
• 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
• Mild Verification of Benefits and Authorization
• Release for SPRCARE (SPRINT PNS)
• Authorization to Release Records to New York State DFS for External Appeal
• Patient Authorization Form for the Intracept® Procedure