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Partial List of Contracted Insurance Companies

Aetna
Anthem
Assurant
Blue Cross
Cigna
Encore
Humana
IU Health
Medicare
PHCS
Sagamore
Tricare
UMR
United Healthcare

Virtual Visit Forms for Samantha Plitt, PA

Instructions

Private Insurance - First Telemedicine Visit Forms

Private Insurance - ABN for subsequent visits

Medicare and Medicare Replacement Plans - First Telemedicine Visit Forms

New Patient Forms

CLICK HERE TO COMPLETE AND SUBMIT NEW PATIENT FORMS ONLINE

Below are our new patient forms to download, print and fill out by hand

Welcome to BalanceMD
Patient Information Form
Medical History Form
Financial Policy
Signature Form

Vestibular Function Testing Information

Vestibular Test Instructions

VEMP ABN

Virtual Visit Forms for Dr. Sanders

Instructions

Private Insurance - First Virtual Visit Forms

Private Insurance - ABN for subsequent visits

Medicare and Medicare Replacement Plans - First Virtual Visit Forms

Virtual Visit Forms for Ashly Gray, NP

Instructions

Private Insurance - First Telemedicine Visit Forms

Private Insurance - ABN for subsequent visits

Medicare and Medicare Replacement Plans - First Telemedicine Visit Forms

Patient Forms