For Patients

Please review the following forms that will be needed at the time of your new patient visit. You may print them in advance of your appointment so that you have time to fill them out and bring them with you. Please note that we do require payment of any co-pays at time of service. We accept cash, check, Visa, Master Card, American Express, and Discover. We also require a photo ID at your first visit. Please do not hesitate to call if there are any questions. There is also a check list for your review below.

Downloadable Forms

-Registration Form

-Health History Form

-Permission to bill insurance

-Office Contract

-Release to leave message

-HIPPA Privacy Notice

-Medication List

Checklist

Downloadable forms (above)
Insurance cards & copay
Referral, if necessary
Driver’s License or valid photo ID
Any tests that pertain to your current problem, IE: EMG, or labs
Any x-rays or imaging that has been done outside of the Lake Health System. Please make sure that you get imaging on a disc and also get the printed report to bring with you.
Any other information that you feel is pertinent to help our physician.
If you are a Workers Compensation patient: please bring your BWC card that has your MCO information on it, as well as your employer information.

Matthew M. Keum, M.D., Inc

Pain Management Clinic

For Patients

Downloadable Forms

Checklist

Matthew M. Keum, M.D., Inc

Pain Management Clinic

Contact Us

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