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Patient Forms
What should I do before my scheduled office visit?
For your convenience, we provide all required patient forms
online. Please download the forms below, print them, fill them
out, and bring them to your scheduled doctor's appointment.
All forms are PDF files and require Acrobat
Reader.
• Patient
Registration and Medical History Form
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Health Insurance:
Please provide us with your complete insurance information and
bring your insurance card to all of your appointments. As a
courtesy, we will submit the claim on your behalf. You will
be responsible for your co-pay at the time of your appointment.
If we do not participate with your insurance company, you will
receive a monthly statement. In the event that a payment plan
is needed, we will discuss options with you on an individual
basis.
 Click here for a partial listing of Insurance Plans
accepted at our office.
Please inquire about participation with your plan on the
appointment form under Questions
and Comments.
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Managed Care Plans:
To accommodate the diversity of approaches to health insurance
in today's managed care environment, we participate in managed
care plans. The key to the smooth processing of your managed
care claim is the Referral Form completed by
your Primary Care Physician. To see us for an office visit you
must provide us with a Referral Form or be willing to sign a
Statement of Personal Responsibility. If your plan requires
a co-pay, this payment is expected at the time of service.
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Worker's Compensation:
If you are injured through your employment or are involved in
an automobile accident while on the job, we will file your Worker's
Compensation Claim for you. Our Work Comp Coordinator will work
with your employer and/or adjustor to make your appointment
after you have informed your employer of the injury.
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Medicare
As a participating provider, we welcome Medicare patients and
are pleased to submit your Medicare and secondary insurance
claims for you.
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Medicaid
As a participating provider, we also welcome Medicaid patients.
If you are participating in the Georgia Better Health Care (GBHC)
program you must provide us with a Referral Form
from your Primary Care Physician. It is your responsibility
to provide the name and phone number of your Primary Care Physician
prior to your appointment.
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Your Responsibility
Our policy requires payment in full at the time of treatment
if you are not covered by an insurance
plan with which we participate. Regardless of your insurance
plan or circumstances for treatment rendered, please understand
that you are ultimately responsible for payment.
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Durable Medical Equipment
(DME)
We provide DME for our patients by using an outside Vendor.
The Vendor usually participates in the same insurance plans
we participate with, but there is a wide variety of coverage
for DME. Some plans cover in full, some pay 80% or 90% with
co-insurance and other plans only cover with the appropriate
rider. You will only receive billing information from the Vendor.
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