The information requested on this form will assist in treating you safely.  Feel free to ask questions. All information provided will be kept confidential unless allowed/required by law and I  will obtain your written permission before release.

Fill out the insurance information if you would like me to Direct Bill. Check with your insurance provider to make sure this is an option for you and if you need a medical note to be covered. Please read and 'sign' the direct billing agreement form at the end.