As your clinician’s practice management and billing company, we will verify your insurance coverage details and inform you of your monetary obligation for your visits. To do so, we need a fully-completed Patient Intake Service Form as soon as possible. Please follow the instructions below to access and return the form:
Click on this link to download the form. Once completed, email or fax the form, along with copies of the front and back of your insurance card to intake-service@nullhushmail.com or fax to 508-433-1871. By email, we can accept scans or photos of the form and card. Please note: our email and fax services are confidential and HIPAA compliant.
Thank you in advance.
*** The above link generates the patient intake form in a PDF format. If you would prefer to view the same form in a Word format, click here.