New Patient – Be Well Family Care

NEW PATIENT REGISTRATION

Please watch the entire video before submitting the form below. We will contact you once we have the availability to schedule with your desired provider. You will receive an email confirming receipt of your form. Please note that it could take several weeks or months for us to call you to schedule depending upon the provider you choose and their availability.

New Patient Registration Form

I have watched the New Patient video.

First Name

Last Name

Date of Birth

Gender

Pronouns

Cell Phone Number

Parent or Contact name

Address Line 1

City

Zip Code

Address Line 2

State

Please list names of family members who see Be Well providers and their relationship to you:

How did you hear about Be Well Family Care?

Your Insurance Plan: Please note that we do not see Medicaid patients and will not be able to treat you if you currently have Medicaid.

I prefer to see a provider under the following payment plan

Stay Well Payment Plan:

$150 per month if you have Commercial Insurance
$170 per month if you do not have Commercial Insurance
$110 per month if you have Medicare

Discounts available for spouses, children, and an annual payment option

Stay Well Providers - If interested in our Stay Well plan, please choose your provider

Swathi Rao, PA-C - Scheduling on an as space is available basis. We will call you when a space opens up.

Angela Henriksen, MD - Scheduling on an as space is available basis. We will call you when a space opens up. Over age 16 only!

No Preference

Functional Fee Payment Plan (non Stay Well)

There are 2 charges associated with most office visits. The first is the $100 Functional Fee which is not submittable to insurance and must be paid at the time of visit. The second is the office visit charge which we do submit to insurance. Anything that your insurance does not pay you will be responsible for. So if you pay out of pocket for your co-pay or deductible you can expect to pay out of pocket for that charge. We do not charge the Functional Fee for a true "acute sick visit" or for a yearly physical - these visits are submitted to insurance only.

Non Stay Well Providers - If interested in our non Stay Well plan, please choose your provider

Ilana Hurrle, NP - Currently has a waitlist

Emily Miller, NP - Now Scheduling for winter.

Amy Goodpaster, NP - Now scheduling on a space available basis. We will call you when a space opens up.

Brandy Protz, NP - Now Scheduling for late summer/fall.

No Preference

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