The NeuroMedical Center’s Patient Forms

For your convenience, The NeuroMedical Center offers all patient forms online, so that you can download and complete them before your next office visit. We highly recommend completing the forms prior to your scheduled appointment to shorten wait times. All forms and documents available for download are in PDF file format.

The NeuroMedical Center Clinic

CLINIC PATIENT REGISTRATION PACKET

If you are a NEW patient of The NeuroMedical Center Clinic, or it it has been MORE THAN 3 YEARS since your last visit, please click the link above to download a printable version of our Patient Registration Packet. You can fill out the form with your keyboard before printing-OR-you can print and fill out the form by hand. On the day of your appointment, make sure to submit your completed Patient Registration Packet to one of the check-in clerks on the floor where your physician is located:

Neurosurgery/PM&R/Pain Medicine: 3rd Floor

Neurology/Neuropsychology: 4th Floor

If you have completed the New Patient Registration Packet in the past, but need to make revisions to certain forms in the packet (i.e. change of address) please download the individual forms you need by clicking the links below:

CLINIC MEDICAL RECORDS RELEASE FORM

If you need to obtain your medical records for personal use, please click the link above and print out the Medical Records Release form. Complete all fields and fax the form to our Medical Records Department at (225) 768-2196 or mail it to:

The NeuroMedical Center Clinic

Attn: Clinic Medical Records Dept.

10101 Park Rowe Ave, Suite 200

Baton Rouge, LA 70810

Our Medical Records clerks are located on The NeuroMedical Center’s 2nd floor from 8:30am-4:30pm Monday-Friday. Please allow 3 to 7 business days for the complete processing of your request. In compliance with state regulations, there will be a cost associated with obtaining your medical records for personal use as outlined at the bottom of the form.

CLINIC NOTICE OF PRIVACY PRACTICES FORM

Download this form for a clear explanation of your rights with regard to your personal health information (PHI).

CERTIFICATION OF MOBILITY IMPAIRMENT FORM

This is the form that must be signed by a physician and submitted to the Office of Motor Vehicles (OMV) if you are seeking to obtain a temporary disability/handicap placard and/or license plate.

PHYSICIAN REFERRAL FORM

If you are a referring physician, please fill out this form for your patient and fax it to our scheduling office at (225) 768-2186.

The Spine Hospital of Louisiana

THE SPINE HOSPITAL OF LA MEDICAL RECORDS RELEASE FORM

The Spine Hospital of Louisiana

Attn: Hospital Medical Records Dept.

10105 Park Rowe Circle., Suite 250

Baton Rouge, LA 70810

Please allow 3 to 7 business days for the complete processing of your request. In compliance with state regulations, there will be a cost associated with obtaining your medical records for personal use as outlined at the bottom of the form.

THE SPINE HOSPITAL OF LA SLEEP STUDY REFERRAL FORM

If you are a medical provider referring a patient to The Spine Hospital of Louisiana Sleep Center please fill out the Sleep Study Referral Form and fax it to 225-906-4839

NOTICE OF PRIVACY PRACTICES

Download this form for a clear explanation of your rights with regard to your personal health information (PHI).

Physician Referral

The NeuroMedical Center’s Patient Forms

The NeuroMedical Center Clinic

The Spine Hospital of Louisiana

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