CALL: 330.455.5011

Appointment Form

SCHEDULE TODAY

Click here to fill out an online form for an appointment request.

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Are You At Risk For Colon Cancer?

VIEW OUR FREQUENTLY ASKED QUESTIONS

Learn who’s at risk and what symptoms to look for. There is a whole host of good questions and answers that will help.

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Patient Center

ONLINE BILL PAY

Click here to securely pay your bill online.

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Patient Forms

Please do not forget to bring:

  • Insurance card or cards
  • Photo ID
  • Current list of medications and dosage

If you need to reschedule or cancel your appointment, please call our office as soon as possible, as this time has been reserved especially for you. Failure to call may result in a charge of $50.00.

Should you have any questions, please call our office: Monday through Friday between the hours of 8:15 a.m. and 4:00 p.m.

We look forward to meeting you and appreciate your cooperation in completing these forms.

After you have made your appointment with our scheduler, please print and complete the following four forms (1) Questionnaire, (2) Insurance form, (3 and 4) both HIPAA forms:

Questionnaire

Please complete the form in its entirety. If you have any questions, please call our office.

Insurance Forms

Please choose the appropriate form focusing on your primary insurance carrier.

Please print out and complete the commercial insurance form indicating that you do not have insurance claims to be filed.

HIPAA

(Health Insurance Portability and Accountability Act)

Please print and sign the letter indicating that you have been informed.

Please print and indicate authority to release information or to decline authorization for releasing protected health information to a designated person.