Phynally PA MMP Pre-qualification Screening Form Fill all form field to go to next step 1 2 3 4 Step 1 Step 1 - 4 Email Address: * First Name: * Last Name: * Date Of Birth: * Street: * City: * State: * Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: * Phone: * Step 2 Step 2 - 4 Please check all that may apply below * Anxiety PTSD Cancer Parkinson's Disease HIV/AIDS Huntington's Disease Sickle Cell Anemia Opioid Use Disorder Tourette Syndrome Multiple Sclerosis Amyotrophic Lateral Sclerosis Epilepsy Intractable Seizures Inflammatory Bowel Disease Neurodegenerative Diseases Spinal Cord Damage with Spasticity Terminal Illness Crohn's Disease Glaucoma Autism Neuropathies Dyskinetic Disorders Spinal Cord Damage NONE Other: Step 3 Step 3 - 4 Do any of the diagnosis listed above apply to you? * Yes No Step 4 Step 3 - 4 Click submit to finish. Step 4 Step 3 - 4 Please select any and all symptoms you have experienced * Nervousness Depression Severe Cramps Fatigue Chronic Post Surgical Pain Cervical / Lumbar Discs Traumatic injuries failed nerve blocks Arthritis Lack of Appetite Severe Headaches/Migraines Carpal Tunnel Syndrome Nausea / Vomiting OTHER ASSOCIATED CHRONIC MEDICAL ISSUES What Day(s) of the week best suit your for your appointment? * Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time of the day would you like to schedule your appointment? * 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Acknowledgment and Consent form I hereby authorize Phynally LLC, a third party HIPAA compliant Business association agreement (BAA) to use or disclose the protected health information for the above named patient as described below to HIPAA covered physicians. The following person, physician, group or entity may receive disclosure of protected health information for the above named patient. I understand that the information used or disclosed to Phynally LLC, is protected health information to an entity in its role as a business associate only to help the covered entity carry out its health care functions. I may revoke this authorization by notifying Phynally LLC in writing of my desire to revoke. However, I understand that the medical provider to whom this authorization is furnished may not condition its treatment to the above named patient on whether or not I sign the authorization. Please sign name below * Send me a copy of my responses. You have successfully completed the application form, here is a list of doctors. We are processing your request. Please be patient. ×
