Patient Forms

New Patient Packet (complete prior to first visit)
Contains Checklist, Pain Questionnaire, Past Medical History, Map, Medical Records Release, Patient Authorization for Disclosure of Health Information, & Financial Policy. Please Note: Make sure this is completed prior to your first visit.

Physician Referral Form
Physicians who are referring patients to Cumberland Pain Associates, PLC may use this form to communicate the purpose of the referral. Contains a checklist of all procedures and evaluations performed at our clinic.

Pre-Procedure Instructions
To prepare for your procedure, please follow these instructions.

Medical Records Release
Please sign this release in order for us to have your records forwarded to us.

Outgoing Medical Records Release
Please complete this release in order for your records to be forwarded to the physician of your choice. Please note: Patients will be charged a processing fee of $20.00 to have their records forwarded.

Authorization for Use of Healthcare Information
Please complete this form so that we may have permission to disclose your health information to those whom you have authorized. (For example: your spouse, children, or parents)

Notice of Privacy Practices
This notice details your rights as a patient and our responsibilities as providers when it comes to protecting your privacy and healthcare information.

Financial Policy
General description of our financial policy and how it relates to you as our patient.

Note: To view or print these forms, you will need Adobe Acrobat Reader. Click here to download it.

Visit Us Today!

Skyline Medical Plaza
3443 Dickerson Pike
Suite 590
Nashville, TN 37207

Ph: (615) 860-3500
Fax: (615) 860-2420