Forms for Patients

Just click on the link below for a downloadable form.

Patient Information Form
Medical History Form
Patient Privacy
Notice of Privacy Practices Receipt

Please complete all forms in black ink.

Resources for Patients

Go to Resources

Breast Feeding and Birthing Classes are available

Insurance and Payment Policy

We are committed to providing you with the best health care possible. If you have health insurance, we are eager to help you receive the maximum benefits allowed. We have developed the following policies and practices with respect to payment and insurance to help achieve these goals.

First, there are some basic matters of which you should be aware:

As medical doctors, our relationship is with our is with our patients, and not their insurance carrier. Your insurance coverage is determined by the contract between you, your employer, and the carrier. We cannot affect coverage decisions. Questions about coverage should be directed to your insurance carrier.

Before seeing the doctor, you must provide us with complete insurance information. Failure to do so will jeopardize your coverage with HMOs, PPOs and managed care companies, and you will be responsible for the charges.

Some carriers exclude some services or tests - such as well woman exams, or thin prep pap tests - from their coverage. We cannot change your insurance coverage.

Our fees are reasonable and customary for the locale, considered reasonable and customary by most carriers, and are covered up to the maximum allowable by those carriers. Occasionally a carrier wll partially deny a claim on grounds that fees are not reasonable. We have no control over these actions and cannot adjust our fees retroactively.

Ordinarily payment for our health services is due when services are rendered. We accept cash and credit cards for payment. If temporary circumstances hinder your ability to pay your account, we encourage you to contact our office for assistance in the management of your account.

If you are a member of a managed care plan for which we are a provider, we will file your claim electronically. Your co-payment and deductible are due at the time of service. If for any reason your insurance carrier denies coverage for your claim, you must pay for our services at our regular fee schedule rate.

It is also important to know that the lab fees are separate from our fees, as they are not part of this office. As such, they are subject to co-pays and deductibles.