These forms are for your convenience prior to your visit to our office. The staff will inform you if you need to complete one or more of these forms listed below. To obtain these, simply click on the form you need you will see a pdf file pop-up in a separate window ready to print and complete.
Link to patient information brochure
link to phlebectomy consent form
link to Sclerotherapy consent form
 
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Dear Patient,

Due to the number of insurance companies we work with, it is impossible for us to know all the covered and uncovered benefits your insurance plan offers. Therefore, you should familiarize yourself with what your plan covers including deductibles, copayments and when the insurance became effective. You may call the number on your insurance card to find this information.

From time to time you will be asked to complete a patients' encounter form detailing patients' information and insurance information. You will be asked about your insurance coverage at each visit to assure that your coverage remains the same and that your insurance company is billed correctly. Insurance companies also require an updated history and physical yearly or whenever your insurance carrier changes.

Co-payments, self pay services and non-insured items will be collected on the day of service.

Our billing is handled through the offices of Scott D. Glazer, MD. We will bill your insurance company directly for all covered sevices. You are responsible for all uncovered services.

Our goal is to assist you in exploring shelter your insurance carrier has benefits for the services we provide. Ultimately it is your responsibility to know your health plan coverage and limitations. We appriciate your cooperation and apologize for any inconvenience it may cause.

Sincerely,

Mark D. Forrestal, MD & Staff
Northwest Vein Care
   

 

link to patient information brochure link to phlebectomy consent form link to sclerotherapy consent form