(Please call your insurance company representative so that they may assist you in filling out the below information)
What services are considered under
*FOR AETNA HMO, CAREINTON, SIGNATURE, AND ALL OTHER REDUCED FEE PLANS OF WHICH THERE IS NO CLAIMS SUBMITTION REQUIRED PLEASE PROVIDE THE EXACT NAME OF THE FEE SCHEDULE TO WHICH YOU ARE ASSIGNED*
Note: Please make sure that your insurance company gives you all of the above information to insure that your claims get filed properly and/or you receive the correct insurance benefit.
If you have a copay, deductible, or payment due it will be expected at the time of visits. We DO NOT BILL.
THANK YOU FOR HELPING US HELP YOU
** If this is a medical emergency, please call 911 immediately! **