Patient Forms

Patient Forms

The following are some forms you may find useful.

New Patient Request Form

Patients wishing to establish with one of our providers should complete this form and follow the return instructions included in the form.

Health Risk Assessment

Patients who are coming for a Medicare Wellness Exam should complete this form and bring it with them to their appointment.

Diagnostic Center Ultrasound Preparations

Patients who are coming for an ultrasound should review this form in advance, as certain exams require specific preparations.

In-House Record Transfer Form

This form is used to ask one of our offices to send your records to another one of our offices.

Insurance & Fees

We participate with the following insurance plans: Aetna (No HMO Plans), Anthem, Cigna, Humana Medicare (No Commercial Plans), Medicare, Medicaid (Virginia Premier & Anthem Healthkeepers Plus), Piedmont Community Health Plan, Coventry Health Care (No Medicaid), United HealthCare, OptimaHealth (No Medicaid), WebTPA – Custom Ink.




Please bring your insurance card and your ID to each appointment so that we can confirm that we have the most up to date information in our records. That will ensure your claims are filed properly for you.

Many insurance plans require that you make a co-payment at the time of your visit. To make it as easy as possible for you, we accept cash, checks, and most major credit cards at our offices.

Should you have any questions about your insurance coverage, or whether a service or procedure is covered, please contact our billing and insurance department and they will be happy to assist you. You may reach them Monday through Friday, between 8:30 am and 5:00 pm.