Forms for Patients

No Surprise Act
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible. Below is the no surprise act disclosure.

 

Release of Medical Records
For release of medical records, please select the appropriate form below:

 

FMLA, Disability & Miscellaneous Insurance Forms
Forms will be completed through your nurse.
There is a fee of $25.00 per completed form.
Forms can take 5 to 7 business days to complete.

  • Please leave all sections to be completed by the healthcare provider blank.
  • If you improperly complete a form, it may cause delays and / or we may request a new form from you.
  • Let us know if you would like your form faxed, mailed or picked up in person.
  • We will contact you when your paperwork is completed.

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