• Welcome to The MediStation

    Patient Information Verification. Please note that all forms completed through this form are encrypted and fully HIPPA compliant.
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  • Insurance Card (Front)

    Please take a photo of your insurance card. Allow access to the camera and when the image is in focus press take. If you do not have insurance, please ask our staff for a Non-insurance form. Complete the form and take a photo of the completed non-insurance form.
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  • Driver's License or Photo ID for Patient or Legal Guardian.

    Please take a photo of your Driver's License or photo ID. Please allow access to the camera, when the image is in focus press take photo.
  • I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize you to render necessary evaluation and treatment to myself/child/ward. I consent to Health Services and the HIPAA Privacy Notice. The practice will bill my insurance company for its services. I consent to all communication, including but not limited to communication about my medical condition and advice from my health care providers by the following means; Voice, text and email. If a check is sent directly to you from the insurance company for this testing, you agree to sign it and send the check directly to The MediStation LLC.

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