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Blue Cross
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Medicare
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Virtual Visit Forms for Samantha Plitt, PA
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
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
VEMP Information - click HERE to complete the VEMP ABN and submit electronically
Virtual Visit Forms for Dr. Sanders
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
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
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