Please fill out the following forms before your visit. If you are uncomfortable filling out these forms online, click on the PDF link and download a printable copy to bring in with you to our offices. If you are unable to print out the forms, please call our office and we will be happy to provide them to you. Thank you!
Please note that we now require a copy of your Medicare, Medicaid and/or Insurance Card to verify the mailing address, phone number, and the spelling of your name as shown to each individual card. We cannot file insurance claims for you without the birthdate and social security number of the policy holder.
We are also requiring a copy of your driver’s license or other picture ID that includes your signature. This is to be able to verify your identity in the event of requests for release of Private Health Care information.
We appreciate your help and understanding of these requests.