Patient Registration

All Field with a * at the end are required
  • Your social security number is used for insurance purposes only. If you do not provide this information we may not be able to verify or submit to your insurance company
  • INSURANCE INFORMATIONPlease bring all of your insurance information and cards to our office on the day of your appointment.
  • Terms and Conditions. I am authorizing the release of medical and other necessary information to process insurance claims, and where applicable, also request payment of government benefits to the party who accepts assignment. Hitting "Submit" authorizes the payment of medical benefits to the physician or supplier for services rendered.We are required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information and to abide by the terms of this Notice. The complete HIPAA notice is available on our website under the patient center and is available to print. They can also be obtained in person in the office.Please check that you understand our HIPAA Privacy Practices and terms and conditions. The complete notice can be found in our patient center on the website or in person in the office **