New Patient Form

All Office Visits: CASH, VISA, MASTERCARD, CHECK, DEBIT CARD

  • I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THE CLAIM AND REQUEST PAYMENT OF MEDICARE BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNATURE ______________________________________________ DATE _____________________________________________________
  • I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW: SIGNED ___________________________________________________ (INSURED OR AUTHORIZED PERSON)
 

Verification