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     Please use the following links to print and fill out our  patient health history forms. The forms are formatted in Adobe Acrobat, in order to view them you will need Adobe Acrobat Reader installed on your computer. If you do not have Adobe Acrobat Reader you can click the link below to download it FREE.

                                                                     http://get.adobe.com/reader/

 

                                                          

                                                     NEW PATIENT FORMS

                                                                

                                                                                                                                                                                           

                                                      

GROUP OR INDIVIDUAL INSURANCE
     We attempt to take out as much of the "insurance hassle" as possible for you. We'll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 60 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding you financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk will be happy to assist you.

 

PATIENTS WITHOUT INSURANCE
     An increasing number of patients do not have insurance, or have plans with limited coverage, such as catastrophic policies. We realize that no one wants to build up a large bill. Therefore, we have several plans so those patients may receive complete care without undue financial difficulty. Of course we are always happy to accept cash, your personal check, MasterCard or Visa.

 

"ON THE JOB" INJURY (Worker’s Compensation)
     If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.

 

PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
     We currently do not accept personal injury or automobile cases. If one wishes to seek care at the clinic, they will be treated as a  patient without insurance, and after treatment has completed, they will be furnished an itemized bill that they can try to submit to their insurance for reimbursement.

 

MEDICARE/MEDICAID
     We do accept assignment from Medicare, but NOT from Medicaid.  Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20%.

 

SECONDARY INSURANCE
     Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.