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The Good, the Bad and the Ugly.......in the ever changing world, we rely more and more on electronic submission. This is true of our direct billing procedure. Due to regulations and 

requirements by the insurance providers, that means more paperwork.....sorry.

 

 

Please fill these out before your first appointment. 

(Just be sure not to leave them sitting on the counter when you come in!)

 

Patient Registration Form

Benefit Assignment Form

Electronic Transmission Authorization and Consent  this must be signed by the person who holds the insurance policy. For example, if it is through your spouse's job and you (or your child coming for treatment) are covered as a dependent, your spouse must sign it and a copy provided to us before we can do any direct billing. If you have your own plan and have secondary coverage through your spouse, we need a copy for each plan. (Sorry, we didn't make the rules, we just follow them!)

We will have 2 more forms for you to sign in office - a consent for treatment and a release of information, but they should not take more than 5 minutes. 

 

No printer? No worries, just be sure to arrive at least 15 minutes before your scheduled appointment 

time and you can fill them out in office. Apologies, but if your benefits are under your spouse or parent, we will not be able to direct bill your insurance plan until the Electronic Transmission Authorization and Consent is signed by the policy holder though.

 

 

Coming in for a Pelvic Health Assessment or for injuries related to a Motor Vehicle Accident?

PLEASE KEEP SCROLLING...........

  

 

Pelvic Health Appointment?    

Please complete this form 

prior to your appointment.

Pelvic Health

 

 

                                                                        Involved in a car accident?

Please complete this form and

bring it to your first appointment if

you have not yet submitted it to

your insurance company.    AB-1