Authorization for Use and Disclosure of PHI

This form is so any other providers you have seen can send your records to us so we can have a complete medical history.  Jacksonville Spine and Pain Center will also use this form to release or send your medical records to another provider on your behalf. Please fill out the form completely, sign it, and date it.


Notice of Privacy Practices

This notice describes how information about you may be used and disclosed and how you can get access to this information.  Please review it, fill out the brief form, sign it, and date it.


New Patient Packet

This is a very important packet.  These forms provide us with your contact information, insurance, whether your injury is a result of a workman’s comp incident or auto accident.  It also requests details about your pain, existing/previous medical conditions and what medications you are currently taking.  It is a very comprehensive document and you will save a great deal of time in the waiting room if you fill this out prior to your appointment.  


For your convenience, here is a list of the insurance we accept: 


Auto/PIP/Med Pay


Blue Cross Blue Shield


Department of Labor

Health Net




United Health Care


Worker’s Compensation

Most Commercial Carriers