Patient Forms & Privacy

Personal Information

It is imperative that our office be provided with current information on you. We must be able to contact you. Please keep us updated of new addresses, phone numbers, place of business and insurance information.

Medical Record Requests

All medical record requests require a signed written release of information present in the patient chart. If a release is not signed the patient will be required to sign a release before processing begins. A copy of our release can be mailed or faxed. All requests for records will be processed within 15 business days. A processing fee of $1.00 for the first page and $.50 per page thereafter, plus any applicable postage will apply (pursuant to Florida Statute, Chapter 395). Payment is due prior to the release of records.

Patient Forms

The following forms can be downloaded to your computer and printed at home. Or fill out the interactive PDF form, save it and email it to us at APM@shcr.com. By filling out these forms ahead of time, you will save a significant amount of time during your initial visit.

New Patient Form

• Dr. Weidenbaum’s Patient Forms
• Dr. Chaitoff and Dr. Regenbaum’s Patient Form

Follow Up Patient Form

Patient Right to Report Complaint

Authorization to Release Information

Notice of Privacy Practices

Receipt of Notice of Privacy Practices

*All forms provided in web-standard PDF format, easily opened using the standard Adobe Acrobat Reader. If you do not have Adobe Reader, you can download it for free by clicking here.

Downloading and filling out these forms prior to your visit enables us to quickly focus on treating your pain, and gives us the necessary information we need to implement the best strategy for bringing you lasting relief.

Disability, Driving and Other Forms

If you have a disability, financial or similar forms that needs to be completed by our office, please remember that we need at least 7-10 days for processing and processing fees do apply. The fee for these forms is $10.00 per page with a maximum fee of $30.00.

Privacy Practices

Our Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. It is given to all new patients, and a copy is available upon request.

West Palm Beach Office

1500 N Dixie Hwy, Suite 103
West Palm Beach, FL 33401
T: (561) 833-8893
F: (561) 833-8939

Office Hours:
Monday – Friday
9:00 a.m. to 4:00 p.m.