For shorter wait times, please complete and bring the appropriate forms to your first appointment.
Please indicate “N/A” or “None” when a section does not apply to you.
NEW PATIENT FORMS
- Adult History
- Child History
- Financial Policy
- Patient Information Form
- Procedure Consent Form
- HIPAA Notice of Privacy Practices
- Acknowledgment of Receipt of Notice of Privacy Practices
INFORMATION TO HAVE ON HAND:
Be advised, if any of the required information listed below is missing it may be necessary to reschedule your appointment until it is available to you.
- Insurance card(s)
- Valid driver’s license or government-issued photo ID
- Insurance policyholder information — this is the person who holds the policy under which you are covered.
- Policy holder’s name
- Social security number
- Date of birth
- Name of policy holder’s employer (if applicable)
PHOTO FOR YOUR MEDICAL RECORD:
Properly identifying patients is the first step in assuring safety in any healthcare system. Proper identification can prevent treatment errors and “wrong person” procedures, and can safeguard patients against privacy violations, billing errors, insurance fraud and even identity fraud.
COPAYS & DEDUCTIBLES:
- Please be aware of your insurance co-pay, deductible, and coinsurance.
- Specialist co-pays may not cover all diagnostic services performed in the office. Please contact your insurance carrier to determine individual benefits.
All co-pays, deductibles, and coinsurances are collected at the time of your visit with no exceptions!
- Obtain an authorization or referral if required by your insurance. Please contact your insurance company or primary care physician for more information.
- Bring any pertinent medical records pertaining to your visit such as scans or test results. This is helpful to diagnose and treat your condition.