Partners in Endocrinology-New patient appointment request

Partners in Endocrinology-New patient appointment request

Please complete this and wait for confirmation from our office that we are able to see you as a new patient). If ok to see, we will send links to our new patient paperwork.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Your health insurance (Please attach a copy of your insurance card front/back to this form so we can verify insurance):*

Commercial insurance (not medicare or medicaid)Medicare (Traditional): We require a referral to review and have limited availabilityMedicare Advantage plan (We are out of network for all medicare advantage plans but we may be able to see you if you have Out of Network benefits. If able to see, we do require a referral and have limited availability).Marketplace plans (We are currently ONLY able to accept Community Health Choice market place plans).Self pay (Please note New patient visits cost $210-320, follow up visits are $84-140; labs may cost $20-100 depending on what is ordered.We are currently closed to new Medicaid/Texas Star/CHC medicaid plans.
Insurance card (front/back)

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Pertinent medical records for review

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Reason for Endocrine visit*

Diabetes type 2Diabetes type 1 (including pump)HypothyroidHyperthyroidOsteoporosisOther general hormone concernsOther
Please note this practice does not manage bioidentical hormones, does not check certain labs like reverse T3. We also encourage patients to first have an evaluation with their Primary care doctor when possible for initial evaluation. We also do not manage menopause or testosterone treatment in women. We are fortunate to have many Gynecologists in the area who practice evidence based medicine who would be better fit to manage this. (Suggestions are Dr. Helen Rhodes or Friendswood Women).

Please read the clinic policies carefully (see website).
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