Forms

New Patient – Adult Forms

Adult Welcome Letter

Adult Health History Form

Financial Policy Form

Release of Records Form

HIPAA Acknowledgement Form

OMNIBUS Rule Privacy Policy

New Patient – Child Forms

Child Welcome Letter 

Child Health History Form 

Financial Policy Form

Release of Records Form

HIPAA Acknowledgement Form

Insurance/Financial

As a courtesy to our patients with insurance, we will gladly submit claims on your behalf.

You may not find us on your insurance company’s list, but don’t despair.  Out of network does not necessarily mean non-payment.

If you have general questions regarding your insurance coverage and our office, please call us.  If you have more specific questions regarding your plan and the level of coverage, please contact your insurance company.

We offer both in-house payment plans and third party financing options (with approved credit).   After your treatment is diagnosed, one of our courteous administrative team members will review payment options with you.

Click here to view our complete financial policy including payment options.

Financing Available Through Wells Fargo (Click here).