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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 dependant, 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. 

 

 

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

 


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.