PATIENT FORMS

New Patients

To help reduce your waiting time, you can print and complete the below forms prior to your office visit. Please bring them with you on the day of your appointment. Please complete all forms.

New Patient Registration (English)

Patient Medical History (English)

Medication History Authorization (English)

New Patient Registration (Spanish)

Patient Medical History (Spanish)

Privacy Notice (Bilingual)

Medical Records Release Form

Your medical records are completely private. To ensure patient confidentiality, and conforming to HIPAA regulations, no information regarding your condition will be released by this office to anyone, including any family member, without your written consent.

Insurance Information

Please send us an e-mail with your complete insurance information before your appointment. This will make your initial visit to our office more pleasant. Please do not hesitate to call if you have any questions.

Our number is (239) 304-2471.

 

PAYMENTS & INSURANCE

Private Practice

We see patients with NO insurance. We accept cash and Credit Cards as well as most health insurance plans. Please contact us for more information.

 

Insurance

We accept most health insurance plans:

 

  • Aetna

  • Avmed

  • Cigna

  • Florida Blue/ Shield

  • Medicaid

  • Medicare

  • Staywell/Wellcare

  • Multiplan

  • Tricare

  • United Health Care

 

 

Please note this is not a complete list of all the insurance plans that we participate with and are subject to change. Please contact our office for more information or contact your insurance carrier.

 

Payment for Co-pays and Self-pay patient charges is expected at the time of service. For your convenience, we accept Cash, personal checks, Visa, and MasterCard.

 

MAKE AN APPOINTMENT

Walk-In Services are available every day during our business hours.
Do you have any inquiries?
Please contact us at any time.
at our Clinic

5580 19th Ct SW, Suite 2

Naples, FL 34116

by Phone or Fax

Phone: (239) 304-2471

Fax: (239) 304-2741

or Book you Appointment online
using the form below
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© 2016 SWLRMC 

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