forms

(Click on form link. Use your browser menu "file>print") to print the PDF files)

New Patient Form – Necessary for your appointment with Dr. Dickens

Download form (in PDF format) here:  NP-Questionnaire

**This form needs to be completed prior to seeing Dr. Dickens or Gary Dunaye, P.A. Please bring it with you to your scheduled appointment filled out as thoroughly as possible.

Workers’ Industrial Injury:

Step1 – Report your industrial injury to your supervisor, prior to scheduling your appointment with our doctors. Make sure you have filled out all the appropriate paperwork required of you by your employer.

Workers’ Compensation Injury Questionnaire
Please fill out this questionnaire and bring it in with you, along with any insurance information you have received from your employer, employer information and phone numbers. Click here to down load a PDF version of the Worker’s Compensation new patient questionnaire.

Workers’ Compensation & Your Medical Mileage Reimbursement

Did you know you can be reimbursed for your mileage to and from the doctors office or any other related visits, using your vehicle, if it is relates to your Worker’s Compensation injury?

This PDF form is capable of being completed prior to print out. Download by clicking on “Medical Mileage Form” below, for the year you are claiming. When you complete the form print it out and mail it to your insurance adjuster for your mileage reimbursement.

Medical Mileage Form – in PDF Format (for travel on or after 1/1/10)
Reimbursement is now 50 cents a mile.

Medical Mileage Form- in PDF format (for travel on or after 1/1/09 )
Reimbursement is 55 cents a mile.

If you have mileage to claim prior to 2009 go to the California Workers’ Compensation site.
Search on “mileage” and download the appropriate year.

Neuropathy Relief Care Program

Download  form in PDF format  here: Neuropathy Admission Application

Notice of Privacy Practice Form

Effective date: August 3, 2009. This form describes how medical information about you may be used and disclosed and how you can get access to this information. Review carefully.
Download here: Notice of Privacy Practices