Please have below forms and requirements completed on or before time of appointment
Payment and Insurance Information
Medical History
HIPPA
No Show Policy
Additional Forms:
If you are suffering from a Headache
If you are suffering from Pain
If you are suffering from a Concussion
What to Bring to the Appointment
- Your insurance card
- Physician referral forms if required by insurance
- Medication-List of current prescriptions and/or over-the-counter medications you are taking, including dose and frequency
- Pertinent information about your medical and surgical history
- Any recent x-rays or appropriate records you may have
Insurance and Payment Information
J. Greg Zoltani, M.D., is a provider for Medicare and most major insurance plans. We provide insurance billing. Anything not covered by insurance will be your responsibility.
We request payment at the time of your appointment for services that are not covered by insurance. Your insurance company may also require you to pay a co-payment at the time of your appointment. When necessary, our staff will work closely with patients who require a payment plan.
If you have any questions regarding which insurance plans we accept or any patient billing concerns, please call us at the phone number below. Questions regarding your coverage and benefits should be directed to your employer or insurance company.
Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
HIPPA Form
Please print out and complete this medical history form prior to your appointment. Bring it with you to the office on the day of your appointment.
Medical History
No Show Policy
It is the policy of the clinic that for consultations or testing, if you are unable to keep your scheduled appointment, you are required to call the clinic to cancel and/or reschedule your appointment 48 hours prior to the scheduled appointment. In the event that you do not call/reschedule your appointment you will be considered a “NO SHOW” and will be charged for the missed appointment.
MISSED APPOINTMENTS OR LATE CANCELLATION FEE IS $75.00 PER-INCIDENT. After 3 “NO SHOW” appointments, you will be dismissed from our practice by certified letter.
No Show Policy