Please contact us for any questions on:
-Billing
-Receipts
-Medical Records
-Misc Request
-Insurance Questions
Please let us know the why you are contacting us so we can notify the proper staff.
*
Billing
Insurance Verification
Records Request
Misc: Please type specific request
Name:
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Last
Email:
Phone:
Comments / Questions:
Medical Release Form
Upload Release Form for Medical Record Release
*
Max. file size: 200 MB.
If you are requesting medical records,
please download and sign this form
. You then upload a signed copy here when submitting your request.
Insurance Verification
Date of Birth
*
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Upload image of front of Insurance Card
*
Max. file size: 200 MB.
Upload image of back of Insurance Card
*
Max. file size: 200 MB.
Insurance Disclaimer
*
I have read and agree to the insurance coverage disclaimer.
When scheduling your appointment, please be advised that supplying us with your insurance information does not guarantee coverage. We do our best to have your coverage verified by the time you come in for your appointment, however please be advised that in the event we are unable to verify your coverage and/or need additional information, you are responsible for fees at the time of service. If you would like your insurance coverage verified and disclosed to you prior to coming in, please notify our office.
Please Confirm