Embedded Files
To become a patient/client :
Complete Intake paperwork -please include your insurance information even if I am not a provider for your insurance,
I may still need to do prior authorizations for various medications and will need this information to facilitate your care. NOTE SIGN that you recieved privacy practices to left of intake paperwork and date and initial NSM privacy practices form (now in fillable formate bellow)
2. Complete Provider/Client Financial Agreement for all private pay patients
Forms are all in fillable format now- contact me if you have any trouble completing paperwork online
Intake paperwork below to register as a patient with me
COMPLETE THIS FINANCIAL AGREEMENT TO AGREE TO FEE PAYMENT DIRECTLY FROM YOU TO PROVIDER,
SUPERBILL WILL BE PROVIDED TO YOU TO APPLY TO YOUR INSURANCE OR HSA FOR REIMBURSEMENT DIRECTLY - note not all insurances will reimburse patient directly you have to check with your insurance.
The agreement to pay directly can be done through bellow link
https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1490s-english.pdf
Medicare reimbursement direct to patient- for non participating provider like myself
to download the form click link above and submit my superbill with this form to Medicare for reimubrsment of allowed fees
If you previously saw me through AFP sign below release; if you want me to send records of treatment with me outside of AFP to another provider please complete Noras release.
This can just be for your record of my treatment of you at AFP
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