Patient Center

Patient Forms

Forms Packet

Save time in the office. Print and complete these forms before your appointment and bring them with you to your visit with us.

• Patient Forms Packet - 11 pages
• HIPAA Privacy Notice - print for your records

Individual Forms

If you need an individual form from the forms packet above, please select that form below.

• Patient Information Form
• Medical History
• Protected Health Information Authorization
• Informed Consent
• Controlled Substance Contract
• Practice Policies Acknowledgement
• No Show/Copay Policy
• HIPAA Privacy Notice Acknowledgement
• HIPAA Privacy Notice - print for your records

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Insurance

We participate in many managed care programs. Most of these plans require members to pay a co-payment for each office visit. The co-payment will be expected at the time of your visit. We will file a claim to the insurance company for the balance.

Insurance contracts are frequently reviewed and changed; therefore, we will ask for a copy of your ID at each visit. Prior to your visit, please contact your insurance provider or us in order to verify our participation in your plan.

If there is a problem with verification of your insurance information, full payment for services rendered will be expected at your visit. Therefore, it is highly recommended that you contact your insurance to verify eligibility.

• Aetna HMO Based Plans
• Aetna NON HMO Based Plans
• Blue Cross/Blue Shield of GA
• Cigna PPO
• Community Care Network (CCN PPO/WC)
• Companion Workplace Health
• Evolutions
• First Health Network, PPO
• First Health Worker's Comp
• Humana HMO/POS & PPO
• LifeWell Health Partners EPO/POS
• LifeWell Health Partners OA
• LifeWell Health Partners PPO
• Medicare
• Private HealthCare System PPO
• State Health Benefit Plan
• Tricare
• United Healthcare - ALL Plans