Request to Establish Care as a New Patient
Thank you for your interest in our clinic!  Because we get more requests to establish care than we have availability, we ask that you fill out this request, thereby adding you to our waiting list.

Please check with your insurance company first before requesting to establish care to make sure we are in-network with your plan.  Next, check that we accept your insurance. Review our list of currently accepted insurances.  You can then return to this form to fill it out.

We will attempt to verify your eligibility before calling you to schedule your first appointment.

Name of Prospective Patient: First:   Last:
Date of Birth:
Street Address (no P.O. Boxes):
Cell Phone:
Email:
Insurance Company:
Insurance Product Name:
Member ID:
Group Number or ID:
Are you a referral? How did you find us?:
Please tell us anything that will help us match you with the best provider for your needs.  If you are submitting information for someone else, please provide your name, relationship and phone number:
I have checked with my insurance company and verified the clinic is in-network with my plan. I will be responsible for the amount of any services rendered not covered due to ineligibility.

 
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