Patient Forms
New Patient Forms Packet
Save time in the waiting room! Please print and complete the following forms before your appointment and bring them with you to your appointment.
- New Patient Forms Packet (6 pages)
INDIVIDUAL FORMS
If you need an individual form, please choose from the list below.
- Notice of Privacy Practices (Spanish)
- Notice of Privacy Practices (English)
- Unaccompanied Minor
- PMH
- No Show
- Financial Fees
- Office Financial Policy
- Financial No Show
- Patient Portal
- Demographics
- IMM Consent
Insurance We Accept
The following is a list of the most commonly accepted insurance plans. If you don't see your plan listed, please contact our office. The managed care health insurance market changes rapidly, and specific coverage questions should be discussed directly with your insurance company or our knowledgeable staff.
- Aetna
- BCBS
- Humana
- United Healthcare
- Oscar
- First Health
- Private Health Care Systems
- Cigna
- UMR
- Ambetter
- Assurant Health
- First Health
- Greatwest
Office Policies
APPOINTMENT POLICY
NO SHOW policy: $25.00. The Provider's time is saved for YOUR CHILD! An appointment reminder is a 'courtesy'.
PRESCRIPTION REFILL
Rx(Controlled Substance) Policy: NO CHARGE! Just call 3 days before completely running out.
BILLING
After 30 days past due, there is A LATE FEE. Please, pay attention to your correspondence. *Payments of copays/balances are the responsibility of the person bringing the child.
