Patient Information

Feel free to take the time and complete our forms prior to your initial visit. Our forms are available in a printer friendly version.

Registration Form (English)

Registration Form (Spanish)

Medical Record Release Form (English Only)

Below is a list of our currently accepted insurance plans. Please note that the accepted plans may vary from month-to-month and from physician-to-physician. Use this list only as a general guideline. It is always best to confirm your plan is accepted when making your appointment.

Thank you for choosing us as your health care provider. We are committed to providing you the highest level of care. The following is a statement of our Financial Policy that we require you to read and sign prior to any treatment. Unless you are a member of one of our contracted insurance plans or Medicare, full payment is due at the time of service. We accept cash, checks, Visa, MasterCard, Discover and American Express.

If the physician is contracted with your plan, the majority of members covered under this type of plan are still required to make some type of payment for service that is rendered to them. This may be in the form of co-payment, deductible, or co-insurance. If your plan has a co-payment, you will be expected to pay your co-payment prior to being seen by the doctor. Co-payments, deductibles and co-insurance are requirements of your insurance plan and we are required under our contract with these plans to collect these amounts from you.

Most of the members covered under and HMO plans also owe co-payments. Co-payments will be collected prior to being seen by the doctor. We are required under our contract with these plans to collect these amounts from you.

All previous balances are to be paid in full prior to additional services being rendered.

COLLECTIONS Should it become necessary for us to utilize the services of an outside collection agency in order to collect the amounts that are owed, you will be liable for agency/attorney fees

Should it become necessary for us to utilize the services of an outside collection agency in order to collect the amounts that are owed, you will be liable for agency/attorney fees.

I hereby authorize my insurance benefits to be paid directly to the above-signed physician realizing I am responsible to pay non-covered services and I hereby authorize the release of pertinent medical information to insurance carriers. Furthermore, I understand and acknowledge that I am ultimately responsible for the financial liability of the services provided.