Click the appropriate forms below to print, fill-out and bring to your appointment:
DOWNLOADABLE FORMS
NEW PATIENT FORMS
HIPAA CONSENT FORM
This form must be filled-out to receive care. Click on the form below to print, fill-out and bring to your appointment:
FLU VACCINE AUTHORIZATION
AUTHORIZATION FOR RELEASE FORM
Fill out this form for authorization for release of medical information to another party.
CONSENT TO TREATMENT OF A MINOR
Fill out this form for authorization to consent to treatment of a minor.
CONTROLLED SUBSTANCE AGREEMENT
MEDICAL RECORDS REQUEST FORM
Fill out this form for authorization to request medical information from another provider.
CONSENT for TESTOSTERONE
INSURANCE AND PAYMENT EXPLAINED
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.
ACCEPTED INSURANCES
IF YOURS IS NOT LISTED, PLEASE CALL TO INQUIRE
Aetna Insurance
Alliance Health & Life
(Most) Blue Cross Blue Shield
(Most) Blue Care Network
(Most) Blue Cross Complete
Champus/Tricare
Cigna PPO and HMO
Health Alliance Plan
Humana
McLaren Health Plan
Meritain
Molina (Conversions Only)
Medicaid
Medicare
Multiplan PPO
(Most) Priority Health HMO/PPO
PHCS
Travelers Medicare
United Health Care
Wellnet
MEDICARE PLANS THAT FMC PARTICIPATES WITH
AETNA MEDICARE
BLUE CARE NETWORK ADVANTAGE
HAP SENIOR ADVANTAGE
HUMANA MEDICARE ADVANTAGE MEDICARE
McLAREN MEDICARE
MEDICARE PLUS BLUE ADVANTAGE
MOLINE MEDICARE OPTIONS
PRIORITY HEALTH MEDICARE ADVANTAGE
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