All patients

• Please bring your insurance card and referral from your Primary Care Provider if required by your plan
• Copay is due at time of registration
• Please bring your Worker’s Compensation Information (if applicable)
  1. Employer’s name and phone number
  2. Name of Worker’s Comp Insurance Company
  3. Address and phone number
  4. Case Manager’s Name
  5. Claim number
  6. Authorization notice from Worker’s Comp that we can see you
• If you have no insurance or are otherwise paying with cash on your own, you will need to contact the office prior to your visit to set up payment options.
• Children under the age of 18 are required to be accompanied by a parent. A temporary guardian is allowed if there is written authorization from a parent or legal guardian.
• If you have had xrays and/or an MRI outside of Martha Jefferson Hospital, please bring the films and the report with you for your initial visit.
• We ask that our nursing home patients bring an aid and/or a family member for EACH visit.
• In addition to the above, we recommend printing and completing the following forms prior to your appointment. This will help make your office visit more efficient. Each document is in .pdf format, and requires Acrobat Reader to open (click to download Acrobat Reader).

  > New Patients to the practice

  > Established Patients not seen in 3 or more years