For your convenience, we have provided an online patient registration form. You can also print a blank form, fill it out and mail it to our office using the address on the form. Patient Registration Form
Please be prepared to provide a copy of your health insurance card. You may also need to provide insurance forms supplied by your employer or insurance company. All patients should familiarize themselves with the terms of their insurance coverage.
It is important for you to know what services your insurance does and does not cover, as any uninsured portion is the patient's responsibility. If you do not know your insurance requirements, we ask that you check on your insurance coverage before returning this form.
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Emergency Contact Information
Patient Insurance Information
Baby's Insurance Information
Upon receipt of this completed pre-registration form, a representative will verify your insurance and then follow up with you regarding any deductible and/or co-payment that may be due at the time of service.
Please bring all insurance cards and driver's license with you to patient registration when you arrive.
If you have any questions regarding insurance or payment options, please contact our financial counselor at 812-842-4240.
Email communications are not a secured form of communications.
If Email notification has been selected, only your confirmation information and requests for insurance information will be sent in the email message. No other patient information will be sent.
If additional information is needed, you will be contacted by phone.