This page contains downloadable forms for patient use.
New Patient Packet: New Patient Packet
ROI-Release of Information Form: ROI-Release of Information Form
Authorized Qualified Individual Form : AQI-Authorized Qualified Indv Form
Claim Resubmission Form: Claim Resubmission Form
If you wish to email completed forms, please attach the form
and send it to: firstname.lastname@example.org
Always identify the patient’s name and chart number (if the patient is an established patient of the practice) and describe why the forms are being sent. (new patient, record copy, test results etc.) Thank you….
An administrative fee of $25.00 may apply for completion of forms. This fee is due in full at the time the forms are presented and is not billable to your insurance. An additional fee of $15.00 may be incurred if revisions and/or updates are requested to forms already completed. Thank you