Alex Simotas, MD

Hospital for Special Surgery
Board Certified Physiatrist
Specializing In Spine & Sports Medicine

Home > Forms


Listed below are many of the forms that you may be asked to fill out during your visit with Dr. Simotas. You may want to download, print and review these forms at home. Fill them out prior to your visit to help expedite your visit time.

Listed under Patient Forms, you’ll find  Appointment Checklist, New Patient and Follow-Up Visit forms. The Appointment Checklist will review all the items you may need for your consultation with Dr. Simotas. Patients coming for their initial visit should complete New Patient  Form and follow up visit patients, the Follow-Up Visit Form.

Insurance forms can be completed on the day of your visit unless you are specially instructed otherwise by Dr. Simotas’s staff.

Patients who are scheduled for procedures may want to review the Pre-Procedure and Post-Procedure checklists.

Patient Forms

Appointment Checklist
New Patient Form


Pre-Prodcedure Checklist
Post-Procedure Checklist

Insurance Forms

UnitedHealthCare Oxford AETNA Agreement
NonParticipation Agreement for Noncovered Insurance
Medicare Non Participating Agreement