NORTHWOODS FAMILY MEDICINE PATIENT INFO
New Patient Forms
New to Northwoods Family Medicine? You can print and complete these forms prior to your visit with us. ** PLEASE NOTE ** In order to be scheduled for a New Patient Exam, you must complete ALL the forms listed below AND submit them to our clinic BEFORE you can be scheduled.
- Past Medical History
- NWFM Billing and Payment Policy
- Demographics / General Info / Consent to Treatment
- Notice of Privacy Practices NWFM
- HIPAA
- Authorization to Disclose Medical Information and Request for Medical Records
Payment
- We are preferred providers for AETNA, Blue Cross, MultiPlan, Cigna, and Tricare. We accept Medicare and Medicaid.
- We offer a 15% discount for patients paying cash at the time of their visit.
- NWFM Billing and Payment Policy
As a courtesy to you, our patient, we will bill your insurance and accept assignment of benefits for most insurance companies. However, it must be understood that the contract is between the patient and the insurance company. The patient is fully and ultimately responsible for any and all charges that are not paid by the insurance company.
Pricing for Common Services
- TB testing: $40
- School Physicals: $60
- DOT Physicals: $200
Northwoods family medicine 