This office does not file for insurance. For private insurance we will provide you with a receipt to allow you to file your claim. This provider is not a participant of the Medicare/Medicaid insurance programs.
IN CASE OF EMERGENCY
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
(THIS FORM MUST BE SIGNED AND DATED)
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.