New Patient Forms

If you would like to save time when you get to the office, please print off the below forms and bring them with you when you come for your first appointment. Please make sure you bring a copy of your insurance card and referral (if needed).

Patient Registration

Medical History Information

Assignments of Rights & Benefits:
“I hereby assign all rights and benefits under my contract with my insurance company to Lisa Benest, MD for the purposes of determining the details of the benefits of my policy and obtaining payment or services given.”

Dr. Lisa Benest Patient Attest

Privacy Practices:
“While we have always kept your health information secure and confidential, a new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice.”

Dr. Lisa Benest Office Payment Policy

Medicare Patient Registration:
“This office is required to keep your signature on file authorizing us to file claims to Medicare for you and to release information to that payor if they require it for proper consideration of a claim. Please read and sign the following statement.”

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