Patient Information & Forms
Advanced Pain Management (APM)
Dr. Kirit Bhalani Dr. David T. CumminsPatient Forms
Please download the following forms and fill them out in advance of your visit.
Welcome To Pain Management Patient Assignment Patient Information Form Authorization Form Pain Management Agreement Contract for Control Substance Consultation Request Pre Op Instructions Insurance Company Participation ListPrivacy Forms
Patient's Bill of Rights Notice of Privacy Practices Privacy Agreement Acknowledgement | Insurance Company Participation List • Aetna (PPO,HMO,QPOS) • Blue Cross/Blue Shield (PPO,PPC,Traditional,Federal,State,Health Options,Blue Options,Advantage 65) • CCN/One Source/First Health (PPO,W/C) • Capp Care • Champus • Cigna (HMO,Open Access, PPO) • Florida Memorial Health Network (HMO,PPO) • Beech Street PPO • DBCC • Daytona Beach News Journal • Employees Health Benefits • ERAU • Florida Healthcare • Fl Hospital Waterman • Focus (WC) |
• Health Partnership Plan • Interplan Health Group • Lake County Board of Commissioners • Medicare • MetraComp Inc. (WC) • Multiplan Inc. (BCE Emergis) • National Provider Network • Private Healthcare Systems (PHCS) • Physicians Health Care Plan (PHP) • PPO Next (k/n/a Preferred Health Network) • ROMAC Lumber & Supply • Stylemark Inc. • Southcare • Tharp Plumbing Systems • Tricare • United Benefits • United Healthcare • Volusia Health Network |
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