Please download the PDF files below and read them carefully. You will be required to sign them during your initial visit with us. Then continue to the online Registration Form.
Rights and Responsibilities.pdf
Assignment of Benefits.pdf
Please fill out each section of the form completely, fields marked with a red “*” are required.
Please include health insurance info even if Workers Compensation or Motor Vehicle Accident is being billed.
Note: Please bring your health insurance card on your initial visit.
** If you have this policy through your spouse, parents or other sources, he or she will be the subscriber of your insurance policy.