Documents Needed Before First VisitNew Patient Registration Requirements • March 11th, 2021
☐ Complete the Insurance Verification Form*This does not apply to Cash-Pay Patients☐ legible copy of PRIMARY & SECONDARY INSURANCE card(s) front & back*We need this information to verify insurance prior to visit being scheduled☐ Fax it to: 1-866-246-5494*Once insurance has been verified, we will contact you and request the patient registration forms. ☐ Complete demographics with patient information & POA contact information ☐ Signed Consent Agreement ☐ Complete Authorization for Release of Protected Health Information☐ Please send in any old medical records that may assist us in caring for you as our patient. You may use the provided medical record release form to obtain this information from your previous physician or hospital. ☐ Please attach a current medication list, if available.
Documents Needed Before First VisitNew Patient Registration Requirements • March 11th, 2021
☐ Complete the Insurance Verification Form*This does not apply to Cash-Pay Patients☐ legible copy of PRIMARY & SECONDARY INSURANCE card(s) front & back*We need this information to verify insurance prior to visit being scheduled☐ Fax it to: 1-866-246-5494*Once insurance has been verified, we will contact you and request the patient registration forms. ☐ Complete demographics with patient information & POA contact information ☐ Signed Consent Agreement ☐ Complete Authorization for Release of Protected Health Information☐ Please send in any old medical records that may assist us in caring for you as our patient. You may use the provided medical record release form to obtain this information from your previous physician or hospital. ☐ Please attach a current medication list, if available.
