• Home
  • About Us
    • Our Story
    • Gallery
  • SERVICES
    • FAMILY MEDICINE
    • OSTEOPATHIC MANIPULATION
    • WEIGHT LOSS
    • IV INFUSION THERAPY
  • Our Staff
    • Dr. Baranyk
  • Contact Us
    • Hours and Location
  • Downloads
    • Membership Plans
    • Private Insurance
    • Medicare/ Medicaid
    • Weight Loss Program
    • IV Infusion Treatments
  • More
    • Home
    • About Us
      • Our Story
      • Gallery
    • SERVICES
      • FAMILY MEDICINE
      • OSTEOPATHIC MANIPULATION
      • WEIGHT LOSS
      • IV INFUSION THERAPY
    • Our Staff
      • Dr. Baranyk
    • Contact Us
      • Hours and Location
    • Downloads
      • Membership Plans
      • Private Insurance
      • Medicare/ Medicaid
      • Weight Loss Program
      • IV Infusion Treatments
  • Home
  • About Us
    • Our Story
    • Gallery
  • SERVICES
    • FAMILY MEDICINE
    • OSTEOPATHIC MANIPULATION
    • WEIGHT LOSS
    • IV INFUSION THERAPY
  • Our Staff
    • Dr. Baranyk
  • Contact Us
    • Hours and Location
  • Downloads
    • Membership Plans
    • Private Insurance
    • Medicare/ Medicaid
    • Weight Loss Program
    • IV Infusion Treatments

medicare/ medicaid documents

  

Do you have Medicare/ Medicaid Insurance? 

Files 1-6: Everything we need you to complete in order to onboard you as a patient.

File 7: Please complete and turn in prior to your first appointment.

File 8: Federal Form, for your information only. 

General Consent and Financial Agreement (docx)Download
Authorization for Disclosure of Health Information (docx)Download
Telemedicine Waiver (docx)Download
No Show Policy - Medicare, Medicaid (docx)Download
Patient Credit Card on File Agreement (docx)Download
Patient Demographic Information (docx)Download
Patient Medical History Form (docx)Download
Notice of Privacy Practices (docx)Download
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