Welcome! Enclosed you will find forms that need to be completed prior to your appointment. We will also need a copy of your insurance card (front/back). If you have an HMO insurance, it is your responsibility that we have your referral on the day of your appointment. If you need to cancel your appointment we ask that you notify our office at least 24 hours in advance. You can leave a message with our answering service as well. Failure to give a 24 hour notice will result in a $50.00 no show fee.
Release of Information Authorization: I, the undersigned assign to the provider all insurance payments for medical service rendered. I also acknowledge responsibility for payment of all medical fees in the event they are not paid by my insurance.
Assignment of Benefits Authorization: I, the undersigned assign to the provider all insurance payments for medical service rendered. I also acknowledge responsibility for payment of all medical fees in the event they are not paid by my insurance.
I give permission for my medical information to be released to the following people.
