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Available Forms

NEW Patient Information Form
Include street address, city, state and zip code
This will only be used to send you appointment messages.

Insurance Information - please enter your primary and secondary (if applicable) insurance information.

Primary Insurance
Secondary (if applicable)

Insurance Release of Information, Authorization and Assignment: I request that payment of authorized Medicare or other insurance company/carrier be made on my behalf to F. Parker Thornton M.D. L.L.C. for any services furnished to me by that party who accepts assignments/physician. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries any information needed for this or a related Medicare claim/other insurance company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to the party who accepts assignment. I understand it is mandatory to notify the healthcare provider of any other party who may be responsible for paying for my treatment.(Section 1128B of the Social Security Act and U.S.C. 3801-3812 provides penalties for withholding this information.)

Please submit, thank you.

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