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Request to Establish Care as a New Patient |
Thank you for your
interest in our clinic! Because we get more
requests to establish care than we have availability,
we ask that you fill out this request, thereby adding
you to our waiting list.
If you are interested in
Medical-Aid-In-Dying, please visit our website www.rmeol.com
Please check with
your insurance company
first before
requesting to establish care to make sure we are
in-network with your plan. Next, check that we
accept your insurance.
Review our list of currently accepted insurances.
You can then return to this form to
fill it out.
Please note at the bottom of this
form you are asked to verify that you have checked that we
are in-network with your plan. This step is
required and we cannot accept any patient without this
verification. Although
some insurance plans allow or require a patient to
select a PCP as part of their enrollment process, you
still have to go through our establishing care request
to become an active patient.
What to expect at your First
Appointment
When the practice
manager contacts you, you can schedule your
establishing care appointment. This first
appointment is to go over your personal health
history, any medications you are currently taking, and
family health history. Physicals or preventative
appointments will be scheduled after
your first appointment.
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| Name of Prospective Patient: |
First:
Last: |
| Date of Birth: |
ex:
1/21/1955 |
| Street Address (no P.O. Boxes): |
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| City, State Zip: |
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| Cell Phone: |
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| Email: |
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| Insurance Company: |
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| Insurance Product Name: |
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| Member ID: |
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| Group Number or ID: |
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| Are you a referral? How did you find us?: |
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Please tell us anything that will help us match you
with the best provider for your needs. If you
are submitting information for someone else, please
provide your name, relationship and phone number: |
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I have checked with my insurance company and verified
the clinic is in-network with my plan. I will be
responsible for the amount of any services rendered
not covered due to ineligibility. |
