Patient Forms

You can download and print the forms you need for your appointment using the links below. Please bring the completed forms to your appointment. These are PDF documents that require Adobe Reader to open them.
[PDF Help]

• Patient Information Form (1 page)
• Patient History Form (3 pages)
• Assignment Benefits/Consent to Treat (1 page)
• Notice of Cancellations Policy (1 page)
• Acknowledgement of Notice of HIPAA Policies (1 page)
• HIPAA Policies (2 pages)
• Perfume Notice (1 page)

What to Bring to the Appointment

• Your insurance card
• Physician referral forms if required by insurance
• A 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

Drs. Hopson, Hurd, and Rosen-Schmidt are providers 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.