NEW PATIENT REGISTRATION

 
New Patient Registration Form


Stay Well Payment Plan:

  • Stay Well Commercial Insurance (In-Network): $160/month or $1,860 annually
  • Stay Well Medicare: $120/month or $1,380 annually
  • Stay Well Self-Pay (Out-of-Network Insurance & Share Plans): $180/month or $2,100 annually
  • Stay Well Child: For children up to age 26, there will be an additional fee of $75/month per child.


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. 

Please fill out a separate form for each family member you wish to be added to our waitlist.

Having trouble submitting this form? Please call us at 317.938.4559 ext. 3 for assistance.