**SECOND**: FOR PATIENTS THAT ALREADY HAVE AN APPOINTMENT - OFFICE PAPERWORK

1) Please bring your Insurance Card, Photo ID, and Co-Pay (Cash only)

2) Bring any Conservatorship or Power of Attorney paperwork if applicable

3) Download, Print, and Bring with you the below 4-page form (click Red PDF image)

4-Page New Admin 2016.pdf
Adobe Acrobat document [307.8 KB]

**FIRST**: TO MAKE AN APPOINTMENT...

PLEASE FILL OUT BOTH FORMS BELOW - WE WILL GET YOUR RESPONSES INSTANTLY

Considering making an appointment? It's easy. Fill in with as much detail as possible the below fields and someone will get back to you on Tuesday or Thursday. The more information you add, the better we can help you. If you already have an appointment download your paperwork above.

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You have entered the following data:

Please correct your input in the following fields:

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First Name: *

Last Name: *

Date of Birth: *

E-mail address: *

1) Cell and 2) Home Phone: *

Social Security Number: *

Male/Female: *

Insurance Company (write "SELFPAY" if paying cash): *

Patient cannot speak/make decisions for him/herself or has a Power of Attorney or Conservator (PLEASE EXPLAIN BELOW IN DETAIL)

I have/had problems with the law

I drink alcohol.

I use/have used street drugs. (please explain in box below)

I have a pending disability/work comp. case.

I have SECONDARY insurance

Please explain any checkboxes above:

Your mailing address: *

Reason for visit (i.e., Depression, Anxiety, ADHD/ADD, Alzheimer's, Med Management): *

Current Medications

Major Medical Conditions/Health Problems

Electronic Signature Required here that you have read both the HIPAA and Privacy Practice Documents in the Button Link Below - - Type your full name *

Note: Fields marked with * are required

Click here to read HIPAA and Privacy Practice

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You have entered the following data:

Insurance form - Required for every single patient (sorry for the repeat of information, this portion goes to our biller and cannot contain any of the sensitive information above)

Please correct your input in the following fields:

Error while sending the form. Please try again later.

First Name (again): *

Last Name (again): *

Date of Birth (again): *

Your Phone Number (again) *

Insurance Company ------ (or write "SELFPAY") *

Insurance ID # ------------ (or write "SELFPAY") *

800/866/877 # on back of Insurance Card for Providers or Eligibility ---- (or write "SELFPAY") *

Your Address (again) *

Note: Fields marked with * are required

ONCE EACH FORM HAS BEEN SENT, IT WILL SAY AT THE TOP:

"Your form message has been successfully sent."

Once you submit, we will start working on verifying your insurance, please give us a few days to call you back to schedule your appointment.

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Practice Fusion

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ONCE EACH FORM HAS BEEN SENT, IT WILL SAY AT THE TOP: