NEW PATIENT CONTACT INFORMATION

If you have a life threatening emergency please dial 911 or go to the nearest emergency room. You may also visit our website for other local sources of urgent care.

VERIFICATION OF INSURANCE, is often the longest step in scheduling, particularly for OUT-OF-NETWORK benefits.

We are IN-NETWORK with the following insurances and able to verify benefits the fastest.

1. Medicare
2. Aetna Insurance- [Majority of Policies IN-Network Including -Strategic Resource Company- [ Aetna Specialty Group Insurance]
3. Cigna Insurance
4. Cigna Great West
5. Tri Care Humana Military Policies
6. ChampVa-
7. GEHA

We are out-of-network with all other insurances and the verification of benefits can take considerable time, up to a month depending on the policy and current staff availability.

In addition, the following plans generally have limited out-of-network benefits and end up being largely self-pay.

1. BCBS Primary Insurance Policies [ All Policies]

2. FHCP-Medicare Advantage Plans- Affiliate of BCBS

3. Freedom, Insurance [ All Plans]

4. Ultimate Insurance [ All Plans]

5. Beacon Health Options [ All Pland]

6. Magellan Health- [ All Plans]

7. Optimum Healthcare

8. WellCare Insurance

IF YOU ARE OUT-OF-NETWORK AND WOULD LIKE TO SELF-PAY PRIOR TO VERIFICATION TO EXPEDITE THE PROCESS YOU MAY USE THE NEW PATIENT PAPERWORK LINK HERE. PATIENTS GOING THIS ROUTE ARE OFTEN ABLE TO BE SCHEDULED WITHIN A WEEK.

YOU WILL HAVE TO PRE-PAY $150.00

ANY CREDITS FROM INSURANCE PAYMENTS WILL ALSO BE REFUNDED ONCE INSURANCE PAYMENTS ARE RECIEVED.

LINK TO SELF-PAY NEW PATIENT PAPERWORK

OTHERWISE...CONTINUE WITH THIS FORM PLEASE INCLUDE ALL INSURANCE INFORMATION AND WE WILL CONTACT YOU ONCE WE VERIFY YOUR BENEFITS.

IF YOU DO NOT HEAR BACK WITHIN ONE WEEK FOR IN-NETWORK BENEFITS AND ONE MONTH FOR OUT-OF-NETWORK BENEFITS, PLEASE CONTACT THE OFFICE AT 352-795-2246 FOR THE STATUS OF YOUR PAPERWORK.

What is your reason for seeking care at this time?*

Date of Birth*

Date

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

WHO IS YOUR CURRENT PRIMARY CARE PHYSICIAN? IF NONE TYPE "NONE"*

MAY WE CONTACT THEM TO VERIFY YOU ARE AN ACTIVE PATIENT WITH THIER OFFICE?*

YESNOI DON'T HAVE A PRIMARY CARE PHYSICIAN

PRIMARY INSURANCE PLAN (INCLUDE FULL PLAN NAME, POLICY NUMBER, GROUP NUMBER, NAME OF MAIN BENEFICIARY)...IF NONE WRITE "NONE"*

SECONDARY INSURANCE, IF APPLICABLE (INCLUDE FULL PLAN NAME, POLICY NUMBER, GROUP NUMBER, NAME OF MAIN BENEFICIARY)..IF NONE WRITE "NONE"*

MAY WE CONTACT THEM TO VERIFY YOUR INSURANCE IS ACTIVE?*

YESNOI DON'T HAVE INSURANCE

WHAT ARE YOUR CURRENT MEDICATIONS AND DOSES? Type "none" if none.*

MAY WE VERIFY ANY CONTROLLED PRESCRIPTIONS ABOVE AS ACTIVE BY CONTACTING THE FLORIDA DRUG ENFORCEMENT AGENCY?*

YESNO

If you have no insurance or out-of-network insurance, how would you like to proceed?*

Please verify my benefits prior to scheduling, I understand this may take considerable time if I am out-of-network.I am willing to be self-pay initially. Any insurance credits received will be returned to me once benefits are verified. Self-pay rate is $150.00 which covers the charges for the initial evaluation. I will use the self-pay link for paperwork above.

NOTE
AFTER REVIEWING SUBMITTED PAPERWORK, WE MAY NOT BE ABLE TO ACCEPT YOU AS A PATIENT AT THIS TIME

THERE ARE MANY POSSIBLE REASONS THAT WE CANNOT DISCUSS (PRIVACY ISSUES, CONFLICT OF INTEREST, AVAILABILITY, INABILITY TO VERIFY INSURANCE, ETC).

THEREFORE, POTENTIAL PATIENTS WILL BE INFORMED OF NON-ACCEPTANCE IN ONE OF THE TWO FOLLOWING WAYS:

1. WE WILL NOTIFY YOUR REFERRING PROVIDER VIA FAX OR PHONE CALL

2. WE WILL MAIL A "LETTER OF NON-ACCEPTANCE" (SEE BELOW) TO THE ADDRESS YOU SPECIFY.

LETTER OF NON-ACCEPTANCE

**IF YOU DO NOT HEAR FROM YOUR REFERRING PROVIDER OR RECIEVE A LETTER WITHIN TWO WEEKS OF SUBMISSION OF THIS PAPERWORK PLEASE CONTACT OUR OFFICE AT 352-795-2208

If we are unable to schedule you at this time, how would you like to receive the above message.*

Please mail above message to my address above.Please notify my referring provider via phone or fax.No reply is necessary if you are unable to see me at this time. If I do not hear from you within four weeks, I will understand that you are unable to schedule me at this time.

If we are able to schedule you, you must review our policies, general instructions, and complete an initial evaluation packet. How would you like to receive this information?

Please give me the establishment paperwork by:*

(Fastest) Texting me a link to the above phone number.Mailing me a letter with the link to fill out online.Call me for a time to come and pick up all of the required paperwork.

SELF-PAY COST

$150.00

DUE PRIOR TO SCHEDULING

If we do not accept your insurance, you will have to prepay $150.00. This covers the first visit cost ($150.00). This is refunded if you are not accepted as a patient.

Self-pay patients may begin the process of submitting new patient paperwork here.

LINK TO SELF-PAY NEW PATIENT PAPERWORK

By signing below I understand and accept the above submission.*

Clear