New Patient Forms


CLICK HERE TO COMPLETE AND SUBMIT NEW PATIENT FORMS ONLINE


ANYONE ENTERING OUR OFFICE FOR AN APPOINTMENT MUST COMPLETE AND SUBMIT THIS COVID-19 QUESTIONNAIRE 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 Information - click HERE to complete the VEMP ABN and submit electronically



Virtual Visit Forms for Dr. Sanders


Instructions


Private Insurance - First Virtual Visit Forms - click HERE to complete and submit electronically


Private Insurance - ABN for subsequent visits - click HERE to complete and submit electronically


Medicare and Medicare Replacement Plans - First Virtual Visit Forms - click HERE to complete and submit electronically

Patient Forms

Virtual Visit Forms for Stephanie Ford, PT


Instructions


Private Insurance - First Virtual Visit Forms - click HERE to complete and submit electronically


Private Insurance - ABN for subsequent visits - click HERE to complete and submit electronically


Medicare and Medicare Replacement Plans - First Virtual Visit Forms - click HERE to complete and submit electronically

Call Us: 888-888-DIZZY (3499)

Partial List of Contracted Insurance Companies


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

Virtual Visit Forms for Samantha Plitt, PA


Instructions


Private Insurance - First Telemedicine Visit Forms - click HERE to complete and submit electronically


Private Insurance - ABN for subsequent visits - click HERE to complete and submit electronically


Medicare and Medicare Replacement Plans - First Telemedicine Visit Forms - click HERE to complete and submit electronically