The information requested below will assist us in treating you safely. Feel free to ask any questions about the information being collected. Please note that all information provided will be kept confidential unless allowed or requested by law. Your written permission will be required to release any information. Please inform us of any changes to your health status/medications, etc.

We are able to submit insurance claims to several providers. If you are hoping to bill directly to your benefit provider, please enter the details below to be added to your file.

Please note, in the event that a claim is rejected or in need of further review prior to processing, payment is to be made in full and a receipt will be provided for submission to your extended benefit provider.