Insurance and Forms
Prior to your appointment, below is a list of forms that we request that you fill out and bring with you at the time of your visit.
- Health History
- Patient Registration Form
- Receipt of Notice of Written Acknowledgement Form
- Patient Consent for Use and Disclosure of Protected Health Information
Payment for services is required at the time of your visit. For your convenience, we accept major credit cards and we participate in most insurance plans. However, you must bring up-to-date insurance documents to each visit. We will file a standard insurance claim for you. This claim is not filed instead of payment. There is a fee for filing out auxiliary forms. It remains your responsibility to learn the extent of your insurance coverage.
About Your Privacy
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your IIHI
- Your Privacy rights in your IIHI
- Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Angela Frye at 286.6565