New Patient Form

Section 1 – Your Information
Section 2 – Responsible Party’s Information
Section 3 – Primary Insurance Information
Section 4 – Secondary Insurance Information
“I request that payment of authorized insurance benefits be made on my behalf to the provider for services furnished. I authorize consent for any medical provider of services ro be used for treatment of care. I authorize any medical information about my dependent or myself be released to the insurance company to determine these benefits payable for relatable services. A photocopy of this assignment is to be considered as a valid original until revoked. I understand that I am financially responsible for charges whether or not covered by said insurance.”
Our facility participates in Electronic Prescribing and will be asking for your preferred pharmacy to submit any prescriptions necessary upon your discharge. To facilitate this process, we will be submitting your phone number and address on file to your preferred pharmacy.