New Patients | webmdpain

New Patients //

How to Request a New Patient Evaluation (3 Steps):

1. Please fill out the "New Patient Form" below so that we may create an online portal and also check your insurance eligibility. Once we have reviewed the submitted information, we will send you a "Welcome" email from appointment@webMDpain.com that states that your ProCheckIn account has been created.

New Patient Form

First Name

Last Name

Last Four Digits of Social Security Number

Phone Number

Birthday

Emergency Contact Name and Phone Number

Home Street Address

Home Street Address Line 2

City

Region/State/Province

Postal / Zip code

Referring Physician Name

Last Pain Physician Name (If you have had Pain Management in the past.)

IF AUTO ACCIDENT, what is your ATTORNEY's NAME and Contact Info?

IF WORK COMP, what is your ADJUSTOR's NAME and Contact Info?

INSURANCE Information (At this time, we do not accept Medicaid)

Primary Insurance Carrier

Primary Insurance Company Name

Primary Insurance Policy/Claim Number

Primary Insurance Phone Number

Please Upload picture of the Primary insurance card if available.

Upload File

Upload supported file (Max 15MB)

Secondary Insurance Carrier (If applicable)

Secondary Insurance Company Name

Secondary Insurance Policy/Claim Number

Secondary Insurance Phone Number

Please Upload picture of the Secondary insurance card if available.

Upload File

Upload supported file (Max 15MB)

Please keep in mind that communications via email over the internet are not 100% secure. Although it is unlikely, there is a possibility that the information you include in this form and in an email can be intercepted and read by other parties besides the person to whom it is addressed. Our online forms and email communication are encrypted and adhere to HIPAA Business Associate Agreement but we cannot guarantee absolute security of such information.

I agree to the terms & conditions

Please expect an email from appointment@webmdpain.com after we review your information. Thank you!

2. Once you receive a "Welcome" email from us confirming that your online ProCheckIn account has been created, please use the link below to log into ProCheckIn and fill out all paperwork under "New Patient" and sign all documents under "Legal Documents."

https://pmi.prognocis.com/prognocis/pmiProCheckIn.html

3. Once all the paperwork and documents have been submitted, please reply to the "Welcome" email and state that the forms have been completed. We will review and call you on your phone to schedule the appointment.

Please call 301-530-7303

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