New Patient Forms

Lafayette Pain Care is pleased to welcome new patients to our practice. As a valued customer of our practice, we maintain complete records on you to ensure that we can always communicate with you promptly, treat you in the most appropriate and effective manner, coordinate with your other doctors where needed, and ensure your care is paid for by insurance or other means.

As a convenience to you, we have included the forms all new patients must complete below. Please click on the link, print the form, complete it in full, and bring the completed forms to your first appointment. If you have questions about these forms, please call us at 765.714.4344.


Pain Management (Watch Video)

For Our Patients

Lafayette Pain Care welcomes new patients who are seeking relief from acute or chronic pain.  We accept physician referrals and work closely with our patient’s primary care physicians to ensure continuity of care. Here are some questions we will need you to answer as a new patient:

  • Who is the referring doctor  and what is their phone number?
  • What kind of pain are you experiencing?
  • When do you experience pain and for how long have you been in pain?
  • Have you been seen by a pain management clinic or doctor before? If yes, where, by whom and when?
  • Have you been discharged or released by another pain center? If yes, when and why?
  • What type of insurance do you have?

Please read through the information on this page and then contact us at 765.714.4344 and ask to speak to a New Patient Coordinator.


Medical Records

Lafayette Pain Care will need your medical records before we schedule your appointment. These records include:

  • Recent office visit notes with your primary care physician or other physician(s) who have been treating the condition for which you are requesting an appointment to see us.
  • A list of current medications
  • Notes from previous surgeries/procedures related to your pain
  • Radiology reports from X-ray, MRI, or CT exams
  • Records from a previous pain management center/doctor (if your condition was previously treated elsewhere)
  • Insurance information.


It is your responsibility to get us the complete list of records.


Payment Information

Lafayette Pain Care accepts many forms of payment for our services. We are happy to work with you on paying for your care.


To our Patients:

To protect your personal health information we use a HIPAA consent form. We understand that you have certain rights to privacy regarding your protected health information. These rights are given to you under the Health Insurance Portability and Accountability act of 1996 (HIPAA). We understand that by signing a consent you authorize us to use and disclose your protected health information to carry out:

-Treatment (including direct or indirect treatment by the other healthcare providers involved in your treatment)

- Obtaining payment from third party payers (e. g. your insurance company)

-The day-to-day healthcare operations of the physicians practice

You may revoke your consent in writing at any time. However, any use or disclosure that occurred prior to the date the consent was revoked is not affected.

We ask all of our patients to complete a patient authorization form while being under your physician’s care. This form specifies those other persons that you authorize to receive limited personal health information such as disclosure of any appointments and those who are released to pick up existing prescriptions.

We do reserve the right to change the terms of the HIPAA consent form and patient authorization form and you may contact us any time to obtain the most current copy of the notices. We will however, never change your authorization without your approval.

For any questions about the credit monitoring service option, please contact our Call Center at 888-849-0976

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