Please complete all the information on these forms and sign at the bottom of the patient information sheet. Please do not use nicknames, but do include a middle initial if you have one. Bring the completed forms with you when you come in for your doctor’s appointment. (DO NOT MAIL THEM IN.) Please bring your photo id, insurance card(s) and prescription card(s) so we may make copies for our records.
Payment is expected at the time of the visit. We accept MasterCard, Visa, and the Discover card. If you have a co-pay, you will be responsible for the co-payment at the time of the visit. There are additional charges for required tests like x-rays and blood, urine, and other laboratory tests. Some insurances apply co-pays to these as well.
The following insurance companies require referrals from your primary care physician if you are seeing a specialist. You must call the primary care physician to make sure he/she has requested approval for a specialist visit from the insurance company. This referral must be authorized before the specialist can see you. Some example of these insurances are: Tricare Prime, TriWest, etc.
What to Bring
When you come to see the doctor, please bring in all medications or a list with dosing instructions, all health insurance and prescription cards along with a picture id. Check in with the front desk. They will copy your insurance cards, collect copays or any other monies due and give you further instructions.
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Policy for Completing Medical Forms / Disability Forms / Cancer Policy Forms Effective March 2014
|Simple medical or disability forms (1 – 2 pages) will be completed for a $25.00 fee per form.|
|Complex medical or disability forms (3 pages or more) will be completed for a $40.00 fee per form.|
|Cancer Policy forms will be completed for a $40.00 fee per initial form.|
|Payment must be received with the form at the time the request is made. Without
|Payments and forms will be collected at the downstairs front desk only.|
|Forms cannot be completed during an office visit.|
|Patients must have been seen by the Physician at Hematology Oncology Life Center within 6 weeks prior to submitting the form.|
|Completed forms will be mailed to the patient’s home address within two weeks.|