Please fill out the demographics and medical history below. This will take about 15-20 minutes to fill out. Please press Submit when done. Please note that there are mandatory fields must be completed before the form can be submitted. Any issues please email

new patient history

Please fill out the demographics and medical history. This will take about 15-20 minutes to fill out. Please press Submit when done. Please note that there are mandatory fields must be completed before the form can be submitted. Any issues please email

Financial Policy & Office Policy FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECK, VISA, DISCOVER, AMEX, AND MASTERCARD. WE ALSO OFFER AN EXTENDED PAYMENT PLANS FOR THOSE WHO SIGN UP FOR AUTOMATIC MONTHLY PAYMENT PLAN Regarding Insurance The filing of claims is a courtesy to our patients, the financial responsibility lays with the guarantor. Your insurance policy is a contract between you and your insurance company we are not a party to that contract. If your insurance company has not paid your account in full within 45 days responsibility will be transferred to that of the guarantor. Payment will then be expected within 30 days. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under your medical plan. Regarding Insurance Plans where we are a participating provider: All co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan we are not participating provider, you will be responsible for any unpaid charges. Inactive Insurance: For patients that come in and their insurance is not active the parent is required to pay for the office visit in the event that insurance does not re-activate health insurance. Once insurance becomes active, it is the responsibility of the guarantor to inform the office of this, and only after insurance pays in full, the parent will receive a full refund of moneys paid. Missed Appointments: We understand circumstances can arise that cause cancellations to be scheduled appointments. However, it is imperative to notify the office 24 hours prior to the appointment time. Please understand the importance of a schedule and the time that is taken to prepare for such appointments. After 3 no shows patient will be discharged from practice. We also reserve the right to reschedule appointments due to emergency conditions. You may call the office at 239-437-5500 or email at Authorization: For Insurances that require prior authorization: Parents/Guardians responsibility to make sure we have an authorization that is up to date before patient is seen. If there is no authorization than the parent/guardian will be responsible for any charges not covered by insurance. Usual and Customary Rates: Our practice is committed to providing the best treatment for your patients and w charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Minor Patients: May not be seen without parent or authorized party, payment is due in full at time of visit even it parent is not bringing patient in . Tardy Appointments: Although circumstances may arise, we are forced to adhere to arrival time policy in order to keep the schedule manageable and to prevent extensive wait times. All new patients are to arrive 30 minutes prior to appointment. Any arrival 10 minutes after the scheduled time will be rescheduled to the next available appointment. Prescription Refills: All prescription Refills / authorizations will take 24 to 48 hours to be called into the pharmacy. No prescription refills will be done by the on call physician after hours. Please leave a message for the nurse or contact your Pharmacy to request the prescription refill. School Forms: All school forms can take up to 72 hours to fill out and send back to the stated recipient. Nurse Calls: Calls to the office for a nurse will be returned within 24 hours. It may not be possible to speak to a nurse when you call, but a your call will be returned by the end of the next business day. Discharge- Discharge from our practice can happen due to inappropriateness toward our staff, violence toward anyone in the office, 3 or more no shows at our practice, failure to may payment for services rendered, non-adherence to providers medical plan, and several other reasons not noted. Patients will be given 30 days of care after discharge so parents can find a new provider for child’s treatment. Thank you for understanding our policies. Please let us know if you have questions or concerns. If you would like a copy of this policy please ask the front desk.