Chevy Chase: 301.215.4154 Tysons Corner: 703.738.4381
  • Chevy Chase
  • Tysons Corner

Patient Forms

New Patient Packet – Medicare Insurance

This is the first part our registration process which requires all patients with Medicare Insurance to fill out prior to the initial evaluation.

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New Patient Packet – All Other Insurances

This is the first part our registration process which requires all patients with any other insurance, excluding Medicare, to fill out prior to the initial evaluation.

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Follow Up Questionnaire – Medicare Insurance

This is the first part of our check in process which requires all patients with Medicare Insurance to fill out prior to a return visits.

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Follow Up Questionnaire – All Other Insurances

This is the first part of our check in process which requires all patients with any other insurance, excluding Medicare, to fill out prior to a return visit.

Download

Medicare Additional Forms

If a patient with Medicare Insurance did not fill out these forms with the New Patient Packet or the Follow Up Questionnaire, please complete these additional forms prior to the office visit.

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HIPAA Authorization

This form gives the office permission to discuss a patient’s medical care with those indicated on the authorization. This must be completed before the office can discuss care with anyone other than the patient.

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Medical Records Release #1

This form gives the patient’s permission to allow another organization to release records to our organization.

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Medical Records Release #2

This forms gives the patient’s permission for our organization to release medical records to an outside organization.

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Maryland Imaging Facilities

This form provides a list of imaging facilities located in the Maryland region.

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Virginia Imaging Facilities

This form provides a list of imaging facilities in the Virginia region.

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Supplement Order Instructions

This form provides instructions on how to order any supplement, other than the Regenexx Advanced Stem Cell Support Supplement, that was recommended to the patient by Dr. Mayo Friedlis.

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StemCell ARTS Educational Seminars

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