Forms

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We're ready whne you are.		   New Patient Form
In order to provide you the best possible care we need to gather some information from you. Please print and complete the form and bring them with you. It's important that you try to complete this before you arrive for your appointment.
Click to download (180kb)

 

 

Patient Referral Form
If you're looking to be referred from your current physician, please download the Patient Referral Form.
Click to download (151kb)

Online Patient Referral Form
Simply fill out our convenient online form by clicking here.

 

  
List of Contracted Insurance Plans for Total Foot & Ankle
Aetna – Group HMO Health Networks of America
Aetna – Elect Choice EPO and EC Open Access Humana Commercial HMO & PPO
Aetna – Golden Choice Medicare Plan (PPO) Humana Choice – Medicare PPO
Aetna – Golden Medicare (HMO) Humana Gold Choice
Integrated Health Plan, Inc.
Aetna – Health Fund Interplan Health Group (Direct Care America & Primary Health Services)
Aetna – HMO and Open Access HMO Medicaid
Aetna – Managed Choice and MC Open Access Medical Group of Ohio (MGO)
Aetna – Open Choice PPO Medical Mutual (SuperMed/HMO Health Ohio)
Aetna – QPOS and Aetna Choice POS Medicare
Aetna – Trad Choice Indemnity and National Advantage Program (NAP) Medicare DME
Aetna US Access Molina Health Care (Managed Medicaid)
Aetna Medicare Open Plan (PFFS) Multi Plan
Anthem Ohio Health Choice
Anthem – Senior Advantage Ohio Health Group – Health Reach PPO
Anthem SmartValue (PFFS) Ohio Health Group – Health Reach PRIME PPO
Beech Street Ohio Preferred Network (OPN) PPO
BWC OSU Managed Health Care Systems
Care Source (Managed Medicaid) PROM/Flora
Central Benefits – No Contract Prime Net
Choice Care Network/Humana Railroad Medicare
Cigna – HMO & PPO TriCare
Emerald Health Network PPO Trinity Health Care (Mount Carmel Health Partners)
EverCare – Medicare HMO United Health Care
First Health PPO United Health Care – Medicare PFFS 
United Health Care – Medicare Products
Great West (formerly One Health Plan) HMO/PPO West Virginia W/C