New Patient Terms

Please review and acknowledge the following before proceeding to the new patient request form.

I am submitting this request for myself as a prospective patient.

I am 25 years old or older.

I understand that the practice is currently full and new patient appointments are strictly space available. If available, appointments are typically 6-8 weeks out. If I was referred by another provider, I will include that information on the form.

I understand that 48 hours notice is required for changes or cancellations. If I miss my new patient appointment, I will not be rescheduled. Missed follow-up appointments have a $125 fee.

I understand that this practice is in network for BCBS and UHC (United Healthcare) ONLY. I am responsible for understanding my insurance benefits and obtaining any necessary referrals. A benefits worksheet is provided for my convenience. Any amounts not paid by insurance are my responsibility.

I understand that this practice is not accepting any new Medicare patients. Original Medicare is accepted for existing patients. Medicare Advantage plans are only accepted from BCBS and UHC/United Healthcare. All other Medicare Advantage plans are out of network and self-pay.

I understand that if I am self-pay, I must have a card on file for automatic payment on day of visit.

I understand that this practice does not generally see patients specifically for disability or legal issues.

I understand that if scheduled, I must return my New Patient Forms at least 5 business days prior to my appointment or it will be cancelled.

Please complete all acknowledgments and questions above.