POLICIES AND FORMS
Valley Pain & Rehab Center Springman Plaza Suite 105 425 E. Los Ebanos Blvd. Brownsville, TX 78520 Ph: (956) 541-9824 Fax: (956) 541-9829 Our Office Hours: Monday, Tuesday, and Thursday 8:30am to 5:30pm Email This Page		DOWNLOAD PATIENT FORMS To download forms, click a link below. To aid in making your office visit more time efficient, we provide our office forms for your convenience. Please download these forms, fill them out fully and bring them with you at the time of your appointment. FORMS IN ENGLISH • PAIN ASSESSMENT QUESTIONAIRE • PATIENT INFORMATION • HIPAA FORM FORMS IN SPANISH • PATIENT INFORMATION FORM • PAIN ASSESMENT QUESTIONAIRE FORM • RELEASE OF MEDICAL RECORDS • HIPPA FORM Note: To view these forms you will need the free Adobe Acrobat Reader. If you don't have it, download it now. OFFICE POLICIES What to Bring to Every Scheduled Appointment Insurance Card Drivers license or valid photo identification Payment for any applicable co-pays Any relevant MRI/CT/X-ray or other studies including lab work and progress notes List of all Medications that you are currently taking including strength and dosing instructions Names and addresses of referring and primary doctors Completed patient information forms Payment Policy Insurance co-payments are due at the time of arrival. If you are unable to provide this, please see the receptionist upon arrival for rescheduling of your appointment. We accept cash and checks, only. No credit cards. Please note: There will be a $30 fee for any returned checks. Insurance We accept most insurance programs and their subsidiaries. Cancellations & Rescheduling Appointments We do not accept walk-in patients. We request that our patients arrive with an appropriate amount of time prior to their given appointment. There will be a $20 fee for cancelled or missed appointments. Initial Consultations We request that your referring physician contact our office to set up your initial consultation visit. The referring physician’s office must also fax to our office any notes regarding your previous care 48 hours prior to your appointment; if they do not, we may have to reschedule your appointment. Referrals & Authorizations You must obtain a referral from your physician (primary care or other referring physician) prior to your appointment. If your insurance requires authorization for a visit to a specialist you must also obtain this authorization number prior to your visit. Medications & Refill Requests You must discuss your medication needs, including refill requests, with Dr. Wells at the time of your appointment. Medications should be taken only as prescribed; please do not request early refills of your medications. Patients are responsible for lost or stolen medications and prescriptions once they leave out office. After Hours Emergencies Please call our answering service at, (956) 541-9824, or proceed to the nearest emergency room for after-hours emergencies.

POLICIES AND FORMS

Valley Pain &
Rehab Center
Springman Plaza
Suite 105
425 E. Los Ebanos Blvd.
Brownsville, TX 78520
Ph: (956) 541-9824
Fax: (956) 541-9829

Our Office Hours:
Monday, Tuesday,
and Thursday
8:30am to 5:30pm

Email This Page

DOWNLOAD PATIENT FORMS
To download forms, click a link below.

To aid in making your office visit more time efficient, we provide our office forms for your convenience. Please download these forms, fill them out fully and bring them with you at the time of your appointment.

FORMS IN ENGLISH
• PAIN ASSESSMENT QUESTIONAIRE
• PATIENT INFORMATION
• HIPAA FORM

FORMS IN SPANISH
• PATIENT INFORMATION FORM
• PAIN ASSESMENT QUESTIONAIRE FORM
• RELEASE OF MEDICAL RECORDS
• HIPPA FORM

Note: To view these forms you will need the free Adobe Acrobat Reader.
If you don't have it, download it now.

OFFICE POLICIES

What to Bring to Every Scheduled Appointment
Insurance Card
Drivers license or valid photo identification
Payment for any applicable co-pays
Any relevant MRI/CT/X-ray or other studies including lab work and progress notes
List of all Medications that you are currently taking including strength and dosing instructions
Names and addresses of referring and primary doctors
Completed patient information forms

Payment Policy
Insurance co-payments are due at the time of arrival. If you are unable to provide this, please see the receptionist upon arrival for rescheduling of your appointment. We accept cash and checks, only. No credit cards. Please note: There will be a $30 fee for any returned checks.

Insurance
We accept most insurance programs and their subsidiaries.

Cancellations & Rescheduling Appointments
We do not accept walk-in patients. We request that our patients arrive with an appropriate amount of time prior to their given appointment. There will be a $20 fee for cancelled or missed appointments.

Initial Consultations
We request that your referring physician contact our office to set up your initial consultation visit. The referring physician’s office must also fax to our office any notes regarding your previous care 48 hours prior to your appointment; if they do not, we may have to reschedule your appointment.

Referrals & Authorizations
You must obtain a referral from your physician (primary care or other referring physician) prior to your appointment.

If your insurance requires authorization for a visit to a specialist you must also obtain this authorization number prior to your visit.

Medications & Refill Requests
You must discuss your medication needs, including refill requests, with Dr. Wells at the time of your appointment. Medications should be taken only as prescribed; please do not request early refills of your medications. Patients are responsible for lost or stolen medications and prescriptions once they leave out office.

After Hours Emergencies
Please call our answering service at, (956) 541-9824, or proceed to the nearest emergency room for after-hours emergencies.