- New Patient Forms -

- For Those with Medicare -

I am out-of-network with Medicare, and as a result Medicare will not reimburse you for your appointments with me.  The form below, called "Medicare Beneficiary Private Contract," outlines how Medicare will not cover any services you receive from me.  Per Medicare rules, you need to sign & date this contract before our first appointment.

- Private Insurance -

I am an out-of-network provider.  If your insurance provides out-of-network benefits, you may be able to receive partial reimbursement from your insurance company for the fees you pay me for your treatment.  I have created this form (see below) to outline the most important questions you should ask your insurance company to better learn about your out-of-network benefits.  You may wish to call your insurance prior to your first appointment with me to verify your out-of-network insurance coverage.