patient registration

You may use this form if you are a new patient. This form collects all necessary personal information.

Patient information

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Title

Unless advance arrangements are made, payment of services is expected at the time they are rendered. As the patient/parent, you are responsible for any charges incurred. Medicaid patients must be eligible at the time of service. We accept assignment of Medicare and require 20% coinsurance after the deductible has been met

(Parent or guardian signature if under 18 years)
Valid until rescinded in writing.
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Responsible Party/Primary Insured

(If different from above)
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Title

Unless advance arrangements are made, payment of services is expected at the time they are rendered. As the patient/parent, you are responsible for any charges incurred. Medicaid patients must be eligible at the time of service. We accept assignment of Medicare and require 20% coinsurance after the deductible has been met

Phone Numbers

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217 West Avenue A, Belle Glade, FL 33411. Telephone: 1-561-992-4888. © 2017 MD Plus, Inc. All Rights Reserved.